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E806 "N NH :� S10n aW Ii pania3a�i <br /> QTY OF MANTECA HQC]F <br /> WASTE HAULIER'S SOU&Q.E C I EMAITON <br /> I- PRODUCER OF Ll()I D WASTE P� <br /> NAME PHONE <br /> PICK-UP ADDRESS j4!-- <br /> Number <br /> 4 Number Street City State Zp <br /> WASTE SOURCE: I) MES'zIC WAS-rEwATER ONLY•from(circle oue). Septic Tack Portable I"oflet <br /> PICK--UP DATE6 � r� TIl�+II� , <br /> . .j�yl QUANTITY 2 <br /> I certify that this waste rovers delivered to the hauler named below for legal disposg atthe <br /> indicated <br /> - <br /> Printed Name of Owner,Occupant or Agee <br /> S a of Owner,pccnpamt or Agent <br /> 2. 4ULER <br /> NAME ooter <br /> BUSINESS ADDRESS(---( <br /> Number Street City State 71p <br /> I certify that the describcd�wwtee Was�Ied by me to the disposal facjkty named below. � <br /> Rece�viag Station Permit No. { 1� Vehicle License No, "► 1 <br /> Panted Name ofHanler <br /> tare of Wwei�t� <br /> 3. RECEIVING STA,'X'TON <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Mant <br /> eca,,CA 95337 � <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility,and that it was <br /> acceptedlrejected(circle one)material tinder the terms of the Receiving Station Permit. <br /> Signat6re of Wiste Facility Operator <br /> a1 <br /> DATE n 15 afE IN s I)�j =OUT NEs QUANTITY <br /> t <br /> , <br /> Rev.02109 QT==jsh fo= <br /> Z d BILA '0N 'lnr <br />