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,-XX <br /> ......... ................. <br /> .. ..­, <br /> xx <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 5058 <br /> PLFASE FRIM:�'NcomPLETE <br /> & wu-L Nar BE AccEnw. <br /> iWaste' Hauler Company Name <br /> .._Vehicle Capacity. <br /> Vehicle License No. Date <br /> T?0) 49-9 tj Key # Load <br /> Complete name, address, type, and quantity of waste source(s). below. A signature shall be <br /> obtained from a representative from each .source,J verifying the type and quantity stated. - <br /> If more than four sources in the waste load; attach 'additional forms..-Random verification <br /> will be made-by SRWC?. <br /> 1. Name: Iv-0,6 _4e% CL_ C <br /> Address: A. di I. L/ gebma <br /> Zip- <br /> Phone No:: ( <br /> WasteType: T: J Quantity: qal. <br /> Signature: <br /> Date: 4e�,7-R <br /> P.M. <br /> Within Stockton city limits? Yes.No <br /> • <br /> Ll <br /> 'Allowable Waists. '.Type:'-P1 ler <br /> aceiappl cab ,numbs I L-in.-space provided"above, <br /> 1- Residential:.Septaqe`. Toilet'p . 3.., Grease Intercqptor.:. A. -special <br /> -.Disharg4" <br /> Stnaunm win not be agimd,ba Mcafm god mRxmibia pwim AR b.mdicatod <br /> A SpecW Pwak mud be cwVk4cd and Vpvvvd by SRWCP bd=&�cb cis anowta. <br /> . . I, the below named waste hauler, declare under. p6alty'of perjury, that to the best.'10 f my <br /> knowledge_1 have accurately.described the type, quantityj;..and source of-'all wastes which I <br /> now request,.to' diepose of at the . �­f ' ' declare, <br /> SRWC.P.-- ..I - urther- under-penalty of perjury, that <br /> I was personally informed by -the owner--- owner's -agent ,: or I .occupants. ,of-theproperty where <br /> this waste was-received ok.lavo! personal- knowledge, thdt this waste .contains only <br /> reeidential'Loeptage or grease, or in�the case o,f R a 'Spec-ial 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 thetruck(s) used to <br /> transport this .waste was -free of all materials �characterized 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 that f ailure'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. qf. my -Waste.Hauler'.P. ermi I t and/or <br /> ..,other penalties as may be allowed by law. <br /> Waste- Hauler Signature <br /> II , Z L <br />