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�} 6Z0 'ON Nd tiZ 6 9Z '9 'upr ;wli paniaOad <br /> CITY OF MANTECA WOCF <br /> WASTE HAULER.'S SOURCE CERTIFICATION <br /> �. FR0DUCER OF'UQUID WASTE �� f <br /> NAME J ,� PH4 - <br /> PICK-UP ADDRESS /,:JO S i-1u�J„ e w Z A,- 0 <br /> Number Street City Stats <br /> zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY£nom{circlee): Sept�c-Yaiu-k�- ortable Toilet <br /> PICK-UP DATE i - v /� <br /> TIME 4 7 QUANI'Ti'Y' a <br /> I certify that this waste was deliwred to the hauler Domed below for ' <br /> legal dispos-4 at the site indicated. <br /> Printed Name of Owmer.Occupant or Agent Sig"tare of Own4,Qccap$nt or Agent <br /> 2. €TIDE <br /> NAME Roto <br /> 13USINESS ADDRESS s <br /> Number street city State zip <br /> I certify that the descrnbed waste was haUl ed/by me to tlxe disposal foci zty named below. <br /> Rec.,eivixig Station Permit Vehicle f iceuse No. 77 Sl <br /> Printed Name of ETaaler --- <br /> Signature of Hauler <br /> 3. REC G$T.ATION <br /> NATYM AND ADDRESS: Ci f Mantua W <br /> City oQCF 2454 West Y'oseutite Ave. -M2mtec2,.CA 95337 <br /> I certify that the hauler move delivered the dcscr�liquid waste to this disposal faciliri,and that it was <br /> accepte&rejected(circle one)matterW winder the terms of the Receiving Station Perzaitn <br /> Slixit#ire of Waste Facwty dperator <br /> DATE i TfE EIT Trvf E OUT NET QUANTrry's-3 <br /> R.ev.02109 o#Fce assi^tmtlfoaW <br /> d ZOIti 'uN AdL� 9102 9 u�r <br />