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2H6 "N AM :6 S[0Z 'S '2nV awil Paniana� <br /> RECEIVE <br /> AUG 0 5 2015 �'Y of ATE-��CF <br /> soma <br /> . WASTE HAULER'S SOURCE CERTIFICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> 1- PRODUCER OF LI Um WASTE <br /> pH <br /> NAME <br /> cL 3PHONE <br /> PICK-iFP ADDRESS <br /> Number Street City State z <br /> WASTE SOURCE: DOMESTIC'W'-'STEWATEt ONLY froom(circle one). tic portable Toilet <br /> I'TG TJP DATE -- l 7 1S TIME J, � QUAN'T'ITY �- a <br /> I certify that this—ante was delivered to the hauler named below for legal disposal at the site indicated. <br /> A <br /> _ <br /> Printed Name of ,Occupant Agent Sitature of Owner, c pant o sent <br /> �. HAULER <br /> NAME to Rooter <br /> BUSINMSS ADDRESS Gr <br /> Number Street City State Zip <br /> I certify that the described waste was hauled <br /> /by me to the disposal facility nated below_ <br /> Receiving Station permit No. ,. / Vehicle License No. f <br /> Printed Name of Hauler Signature of Hjuler <br /> 3- RECEXVING STATION <br /> N'AIVIE AND ADDRESS: Ci of W � <br /> City QCF 250 Wert Yosemite Ave. Manteca,,CA 95337 I <br /> I <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility,and that it suns <br /> accepted/rejected(circle nue)material under the terms of the Receiving Station Permit <br /> Signs ' e of Wa' a Facttity Operator <br /> DATE TIDE IN � f e�, � / � <br /> i TME OUT T NET QUANTI T 1gals <br /> — — <br /> key.02/09 office assr�fvims <br /> I <br /> A BH "N 06l :6 M6 'S '21V <br />