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ii <br /> .. <br /> I <br /> :,.4d <br /> am <br /> 1GION�A WASTEWATERmf]N'FOL FA "Y' <br /> .......... <br /> 4 <br /> TO BE COMPLETED BY "WASTE HAULER BEFORE 'ENTRY TO SRWCF. <br /> i 5101 <br /> .I i <br /> PLEASE PRINT AND PRESS HARD. INCOMPLBPE OR R EGG n FORM WILL NOT 88 ACCEPTED. <br /> Waste -Hauler Company NameiE <br /> - Vehicle Capacity <br /> Vehicle License No. Date L/,Z Key #^/ Load # <br /> Complete name, address, .type, and quantity of waste sources) below:. A signature shall be <br /> obtained frog a representative each source,'�"verifying the type and quantity.stated. <br /> If. more thea four sources in the waste load; attach.,additional forms. Random verification <br /> willbe-madeby-SRWCF. <br /> ! 1. Name: <br /> Address: <br /> r zip <br /> Phone No.: ( } 1 <br /> .Waste .Type: P' QuanttJ7 gal. <br /> I Signature: _ <br /> ( Date: 2/. C,,2-,Time: <br /> I, I <br /> Within Stockton city limits? Yes <br /> L�o <br /> . <br /> Allowable Waste .Types- Place applicable -number ii!.space provided above. <br /> 1.. Residential Septage` 2 -Portable Toilet` 3..Restaurani Grease Interceptor 4 Special <br /> Disharge" <br /> s .M act ba pimd, row and r >i� &.a be> <br /> A Sp=W Pumk mina be eampkmd and a wwnd by SRWCF before&scfxfa u allowed. <br /> 'I', the below named.waete hauler, declare under penalty.:of' perjury, that :to the best -of my <br /> 'knowledge I-have accurately described the -type, -quantity,. .and. source of:all 'wastes:which I ' <br /> :,now request to ,dispose. of at:the ..SRWCF. 'I further' declare; under penalty of-perjury, .that. <br /> I _waa personally informed'by the,owner,-. owner's :agent, °or occupants..of `the -property where <br /> this waste was -received or -have personal.knowledge,--that this waste,contains only.. r. <br /> residential "se <br /> pta ge -or grease, ..or -in the case of;flja Special Permit, 'is not'.hazardous and . <br /> does not exceed previously -authorized .limits-, as;per Pretreatment/Source Control <br /> requirements. -' I also declare,..under .penalty "of, perjury, -that" the truck(s) "used 'to <br /> j transport this waste was free-of all -materials character ized "by:"law as a hazardous waste <br /> or substance at the time of said -use... I am aware"-of the conditions and requirements of <br /> the Waste� Hauler Permit. Further, I understand ihat ;failure .to "accurately .describe -the + <br /> i above information or failure to comply urith my Waste Hauler Permit and/or,any applicable <br /> I. SRWCF regulation, may result In the immeldiate suspension..of-my Waste Hauler,Permit and/or <br /> ed <br /> ,other penalties as may be allowby:law.. i ! <br /> waste 'Hauler.Signature �? I <br /> r <br />