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TOE 'COMPLETED B <br /> N <br /> COMPLETED BY WASTE HAULER BEFORE <br /> I RZASE PRIM , ENTRY TO SRWCF. 5102/'1 e� <br /> waste Hauler Rin. VC0hWL�oRInixa ma Pons�NOT HE At CFPTfD. J V L <br /> f Company Name <br /> Vehicle License No. Vehicle Capacity ) I <br /> L4 Vehicle�. Date r <br /> Complete name, address t — Key # Load # <br /> obtained from a representative from each source, verifying the type as <br /> quantity s of waste soyrce(a) below. A signature shall be <br /> r �f If more than four sources in the waste load; attach additional forms <br /> Will be made by 81twC8. d quantity stated. <br /> _ i� . Random verification <br /> 1. Name: <br /> j Address: <br /> € ' <br /> I Phone No. : ( } <br /> Waste T <br /> YPe- �`ity. <br /> Signature: ;t. - — 7gal. <br /> Ii Date: _ <br /> 6 Time: <br /> Within Stockton city limits? Yes o <br /> f <br /> r <br /> s <br /> I <br /> i <br /> -Allowab2e Waste !' ... <br /> eptag Place applicable number in space-.provided ,above. <br /> 1. Residential Septage' 2. Portable Toilet'.. 3. .Re'staurant. Grease I <br /> Disharge' nterceptor ";4. ..5 j <br /> pedal <br /> ss .at net be ,but <br /> p <br /> A s ;.i Pumit I-AbM and ftq oaJ,pQi I sh.n be IiodieaW <br /> mwt be*=Phftd,md VPrQ W by sRwcP bdere - <br /> di.*.j,a+uoared. <br /> I, the below named.waste hauler, .declare under I� <br /> knowledge I .have accurate ly. deseribed the t penalty of per u <br /> now request 'to dis type, quantit j rY, that to' the beet :of my ! <br /> I was Pose of at the SRWCF. ... I furtherlCdeclareunderzce of all wastes. which I <br /> personally informed b penalty of <br /> y the owner,-. owner's. agent, or occupants of the Perjury, that . <br /> this waste was received or have personal <br /> residential Septage or. knowledge;Ithat this -waste contains only <br /> y where <br /> does not exceed grease," or in the case of a Special Permit, is not hazardous and <br /> Control - <br /> requirements. Ipalso adeclare, under penalty, of i <br /> transport p Per Pretreatment/Source Control " a <br /> Po this waste was free of all materials characterized b <br /> or substance at the time of said use. . I ria perjury, that the truck(s) used uto <br /> s <br /> the Waste Hauler Permit. ware of the conditions and y law as areg firemen waste ' <br /> Further► I understand that failure to accurately describes the <br /> above information or failure to comply with my Waste Hauler Permit and o <br /> SRWCF regulation, may result in the immediate sus <br /> `ger penalties as may be allowed b / r any applicable <br /> y law• pension of my Waste Hauler Permit and/or <br /> Waste Hauler .Signature <br /> q <br />