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H06 'ON AdH :: SIOZ� ;Z. �lnaWIl paAIa�a�' <br /> CTTX OF MAN'TECA)yQCF1H 111111111� <br /> WASTE HAITLER°S SOURCE CERTITICATION <br /> L PRODUCER OF L1 U WASTE <br /> pH <br /> NAME <br /> n IS Z- ��_CN � PHONE� -c , .3 —�xxx <br /> PICK-UPADDRESS_]. �[j G e <br /> �,. cam_ f-c4) /"4 . ,? I <br /> Number Street --- —_ c`, <br /> city ._. .$tete � i <br /> WASTE SOURCE: <br /> /DOMESTI/C WASTEWATER ONLY from(circle oge): Sep�c Y a Portable Tollet � <br /> PICK-UPDATE Co " ��` J� T3ME / f <br /> .' �� QUANTITY <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated. <br /> taPrinted Name ofO►vner,Ont or Agent <br /> Signature of Owner e¢upaz or Agent <br /> 2. gADy ER <br /> NAME o#o Raoter r { � J <br /> BUSIKESS ADDRESS �1/?,�: 77l�i • �/1(' c i L f C) <br /> Number Street City State <br /> zip <br /> I certify that the descnbed waste was hauled by me to the disposal facility named.below. <br /> Receiving,Station Permit No. �r/ ! Vehicle Li <br /> cense Na. <br /> Printed Name of Harrier f �" <br /> Signatttre of Hauler <br /> f <br /> 3. RE&C_E1V-WG STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,CA 95337 <br /> i <br /> I certify that the bauler above delivered the dcscn1>ed liquid waste to this disposal facility,and that it was <br /> accepteWrejected(circle one)material under the germs of the Receiving Station Permit. <br /> ` Signatti re of Waste Facility Operator <br /> DATE T1ME 7N - _TIME OUT�NET QUANTITY – gals <br /> Rev.02/09 office assistantlforms <br /> I <br /> d E[Lz "N AdH :: SAH z Jnr <br />