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f l <br /> i <br /> STCTU1GIONAVSTEVVATE C©N'TROL FACILT { <br /> { ' W S' "E A R S. F0 <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. <br /> 5103 <br /> PLEASE P1tW PRESS HARD. COMPLETE OR RIXANEU FORMS WILL NOT HE ACCEPTED. <br /> Waste Hauler Company Name_ 6TU 11471,44-JQ-:! Vehicle Capacity �7 � <br /> Vehicle License No._ 4 �- 3,:5-,� Date 11- -/0-V Key it Loadl U <br /> ; j Complete name, address, type, and quantity of waste source(s) below. A signature shall be <br /> obtained from a representative from each source; verifying the -type and quantity stated. <br /> I If more than -four sources in the .waste load; attach additional forms. Random verification ' <br /> will be made by SRWCF. <br /> 1. Name: P A <br /> I <br /> Address: . <br /> At <br /> F zip- <br /> Phone No.: ( 3a <br /> Waste Type: i.." uantity: /7&�gal � <br /> Signature: <br /> f Date: -.moi" Time: A.M. <br /> Within Stockton city limits? Yes No <br /> �k <br /> .i <br /> I a <br /> S } <br /> I <br /> Allowable Waste : Place applicable able.numb <br /> er .� <br /> 1'YPe ;<n space PP provided above. '. <br /> P <br /> 1. Residential Septage. 2. Portable Toilet* .•3.. Restaurant Grease -Interceptor' 4. Special <br /> F Dishargei - <br /> Simahau w M ant be:nVxi vd,bat bm im gad mwassI pcmw diad be;adicabed <br /> A SpeeW Pam6 w"be camplemd wd appwnd by SRWCF be&=diwhuge is-Bo iM. <br /> I, the below named waste hauler declare under <br /> , � penalty of perjury, that to the best of my <br /> EE knowledge I .have accurately described the type, quantity, and source of all wastes-which I' <br />'I now request.to dispose. of at the SRWCF.:, I further declare, under penalty of, <br /> f perjuiry, that . <br /> I was 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 <br /> residential septage or grease, .or in the case of`,a Special Permit, is not hazardous and i <br /> does not exceed. previously authorized limits,- asliper Pretreatment/Source-.Control <br /> requirements.. I also declare, under penalty of perjury, .that the truck(s) .used to <br /> transport this waste was free -of allmaterials characterized by law as a hazardous waste i <br /> � . or substance at the time of said use. I am aware of the conditions and requirements of <br /> the Waste Hauler Permit. Further, .1 understand that failure to accurately describe the <br /> above information or failure to comply with my Waste Hauler Permit and/or any applicable <br /> SRWCF regulation, may result in the immediate suspension of my 'Waste Hauler Permit- and/or <br /> other penalties as may be. allowed by law. <br /> Waste Hauler Signature <br /> I :4 : AKr . <br />