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8SN "N '2nV mull pania3;� <br /> FIECENEU woo <br /> AUG 0 5 2015 CITY OF nLkNTECA w CF <br /> EN4R0NMENTALHEA1-TH . WASTE MAULER'S SOURCE CERTIFICATIO <br /> PERMITISERVIGES <br /> 1. PRODUCER OF LIgUID WASTE <br /> - p <br /> 1'Ir.1v,1.A.i PHONE.�o l',f.� <br /> PICK-UP ADDRESS I,�- 6,3C) ;r vt ( 44, IF 53 ell <br /> Number Street City State Zip <br /> ' I <br /> WASTE SOURCE: DOMI✓STIC WASTEWATER ONLY from(circle one): epttc T Portable Toilet <br /> PICK-UP DATE Z-w,�C� QjJT, <br /> I certify that this wrote was delivered to the hauler named below for Iegal disposal at the site indicated <br /> Printed Name of er,Occupant or ent Signatu�ofwner,Occnp t or Age <br /> 2. A&ULIER <br /> N.A.M . Rata Rooter <br /> BUSINESS ADDRESS <br /> Number Street City State— Zip <br /> I certify that the described waste was horded by me to the disposal facility named below. <br /> Receiving Station Permit No. Vehicle License No.Z76,i5: _ <br /> r II <br /> Printed Name of Rattler Signature of H4uler <br /> 3. MCEIVIN G MAT-10N <br /> NAME AND ADDRESS: City of Manteca WQCF 24.50 West Yosemite Ave_ Manteca,CA 95337 <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility,and that it was <br /> accepte&rejected(circle one)material under the terms of the Receiving Station Permit. <br /> ,Sighe of Waste Facility Operator <br /> DATE � �� J 1 57- TIME IN r 1 �� r� TIME(VTNETQUANT i �r�f�' S <br /> t <br /> I <br /> i <br /> Rev.OV09 office assist fonas <br /> 'd B66 "N Wall 6 (� [OZ 'Ij '2nd <br />