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i <br /> ti�M 'IN AV�S : OI SIOZ '9 'APA awil pania);� <br /> CTT3tr OF 1VLANTEC.A W CF Howe <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> I- PRODUCER OF LI UID WASTF / <br /> pH__L <br /> NAME PHONE f`�. L <br /> PICK-UP ADDRESS �Jr'-)/, In i,j <br /> Sia i <br /> Number Street City State <br /> zip <br /> WASTE SOURCE: DO S C WASTEWATER ONLY from(circle one�ttc Portable Toilet <br /> PICK-UP DAT'-- �C� <br /> ._ QU' Y' C t� gals <br /> I cmtify that this waste was delivered to the hauler named below for legal disposal at the site indicated. � <br /> r, <br /> Printed Name of Owner,Occupant or Agent <br /> Sigaatrn-e of Owner, ccupant or W--tit- <br /> 2. <br /> g t2. HAULER <br /> NAME oto R <br /> BUSINESS ADDRESS . ; u G t / G [ l j G <br /> N'um'ber Street City State Zip <br /> I certify that the described waste was hauled by sae to the disPosal facility named below. <br /> Receiving Station Permit No-�7t _ Vehicle 7 accuse No. <br /> Printed Name of Hauler Sigaatere ofnler <br /> 3. RECtMING S'T`ATION <br /> NAME AND ADDRESS_ Of W � <br /> �y QCk' 2450 West Yosemite Ave. Manteca,.CA 85337 � <br /> I cert*that the hauler above delivered the described liquid waste to this <br /> tetUre-ected � �°�fic��and that it was <br /> acce <br /> P ] (circle oae)material under the terms of the Receiving Station Ptnit. <br /> C(( ataste FaOaSigir Operator <br /> r <br /> DATE �O S ' r /, <br /> TlNLE IN { TMEE OUT I [llt3 NET QUANTUY 3,?6+0 <br /> i <br /> _ I <br /> Rev.02/04 office aSsisWVf,= <br /> I <br /> 'd tiM 'ON AOS 01 SAH '9 ��W <br />