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tiHO "N NdtiZ : Z 9lOZ '9 'U�r ;Ili pania);� <br /> CITY Q <br /> F 1VLA NTECA EQ CF <br /> 'WASTE HAULER'S SOURCE CERTIFICATION <br /> 1- PRODUCER OF LIOM WASTE PH�t <br /> NAME �it. L� PH4 �—` � <br /> PICK-UP ADDRI;ss [�3 S- �lr�r t ��-41 � <br /> Number Scree# City statep <br /> 2;ip <br /> WASTE SOVRCM DOMESTIC W_AsTEVvATER ONLY fium(circle one). Sa tic T <br /> Portable Tvilet <br /> PICK-Up DATE_Z�� <br /> OUANITTy <br /> I cerdfy��that this wwte was deli-,ered to the baulcr named below for legal disposal at e site wdicat� <br /> Printed Nance of Owner,OcG =t or <br /> � Agent Suns of Owner,OcettpsAt or Agent <br /> 2, <br /> NAME Roto Rooter y— ; <br /> BUSINESS ADDRESS �� / ��1 Cis') �c �ir. n <br /> Number Street City St31 � ip��' <br /> Zip <br /> I certify that the descTibed waste was hauled by nae to the disposal facffity named below, <br /> Receiving Station PetYna#No. _ 'Vebicle Licc=No. <br /> Printed Name of Ruler <br /> Signature of Hauler <br /> i <br /> 3- I2E if <br /> G S�'A'I'iQ�N <br /> MANE AND ADDRESS; City of Manteca WQCF 2450 West Yosen3jte Ave. Manz <br /> eca,-CA 95337 <br /> I certify that the hauler above delivared the described liquid waste to this disposal facility,and dist it was <br /> aceeptedlrejected(circle one)material under the terms of the Receiving Ststiou Permit. <br /> Sig�a�`ure of sate scili�Ogers#�c <br /> DATE l'7 5 TIl1 IN UY' TMM OUT NET QUANITTY�5 gals <br /> Rev_02/09 of ass-&=Vf m, J <br /> .I <br /> Z 'd Zflti '°N NdLZ :Z 91H '9 'U�r <br />