Laserfiche WebLink
E806 "N WdH :: Sl0Zz nrcauail paniaaa�f <br /> CITY <br /> OF LECA tiVOCF <br /> WASTE HAM;R,R'9 54LaCE CRTgSCATT N <br /> I- PROD FR OF LIOLTIED WASTE <br /> PH t <br /> /f <br /> NAME PHONE : `" fl <br /> PICK-UP ADDRESS fd�C� � i v� / ifYZfDI/� CL't `� <br /> dumber Street City State Zip <br /> WASTE SOURCE: DOMES'T`IC WASTEWATER ONLY from(circle one): tiC T Portable Toilet <br /> / l � I <br /> Pick-up])ATE Ln f � �� TII'IE L' - �L� f <br /> . �- QuANrrl-x �,;Z <br /> I oertify that this waste was delivered to the hauler named below for legal disposarat the site indicated. <br /> n � � <br /> Printed Name of Owner O¢ an Agent S62 <br /> ture of Owner, cc panto eat <br /> I <br /> 2. HHAULFR <br /> NAME R to Rooter <br /> BUSINESS ADDRESS , .% . <br /> Number Street City State Zip <br /> I certify that the described waste was hauled by me to the disposal faczaity named below. <br /> Receiving Station Permit Na. �` Vehicle License No. �y�' <br /> Printed Name of Hauler <br /> Signature of$4uler <br /> 3. RECX"-- G STATION <br /> NAME AND ADDRESS: cityof Manteca W i <br /> QCF 2450 West Yosemite Ave. Manteca,-CA 9533- <br /> 1 <br /> I certify tltat the hauler above delivered.the descnbed liquid waste to this disposal facility,and that" was <br /> aeceptedhejected(circle one)material under the terms of the Receiving Station permit. <br /> S" attire o ante Facility operator <br /> DATE 2j Q-�5_ =IN �' 5 TD&F OUT �1 NET QUANTITY gals <br /> Rev.02/09 office assi.=dfo= <br /> •I <br /> `d ��Lz 'ON [ nr <br /> i <br />