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062 "N Wd00 :Z S [06 '0l ,ung ;W1 j pania)ad <br /> CITY OF-NL LA, ECA WQCF <br /> WASTE H,A,ULER'S SOURCE CERTIMATION <br /> 1. PRQYIUCER OF LIQUID'C'ir�aASTE <br /> pH <br /> NAME S PFiOl �o ,,�5� 1� . <br /> PICK-UP ADDRESS r'� S �,,Y . L ;�G►�-a � 3 j <br /> Number Street City State Zip <br /> WASTE SOMCE: DO?jESTIC WASTEWATER ONLY from <br /> (circle one): optic T Portable Toilet <br /> PICK-up DATE TIlVJE QUANT i <br /> I certify that this waste was delivered to the hauler named below for legal f <br /> � +sg disposal at the site indicated <br /> '! �, �.<�U"tom`.• �';` � j <br /> PrintedName of Owner O cttpant omen` Signature of Owner,Occupant or Agent <br /> 2. HAL'I,ER <br /> NAME R ooter <br /> 13USIITESS ADDRESS � �?' 2le.��k-4 <br /> Number S r ` 'C <br /> treet City State Zap <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station permit No. Vehicle Liceuw No.�4 - <br /> Printed Name of Hauler Signature of H4uler <br /> :f <br /> '1 <br /> 3. RECFx_nG STATIN . <br /> NAMEOND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,CA 95337 <br /> I <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material under the terms of the Receiving Station Permit. <br /> Signature of Waste Facility Operator <br /> DATE ?-:,�- TIME IN A';'�. TIivM OUT _�1,`1% „NEST QUANTITY <br /> I <br /> - I <br /> I <br /> Rev.02/09 office assistaxa/fo= <br /> z 'd �LtiZ 'ON <br />