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o Ap awi ;AI ;); <br /> ti�98 ' N Wd�S �0 l � l OZ '9 W 1 P � <br /> QTY OF MANTECA W CF .a•* <br /> WASTE HAILER'S SOURCE CERT)FZCA-D <br /> I. PRODUCER Qg LIOLZb WASTE P, <br /> pxoNl; <br /> P1CIL ADDRESS 3 L �S ' zdi <br /> Number _7 <br /> Street City -- State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY.from,(circle one): tic Tank Portable Toilet <br /> PICK UP DATE �. TugE �• !� Q[TANTTTY <br /> I certify that this waste was delivered to the hauler named below;For Iegal&spoo at the site indi <br /> Printed Name of Ownet',Occupant or Agent Signature of Owner, ccupant or Agent <br /> Z, HA ER <br /> NAME oto Roa ��`` . <br /> BUSINESS ADDRESS !L-- <br /> Number Street City State Zip <br /> I certify that the described waste was hauled by me to the disposal facility named below- <br /> Receiving Station Permit No <br /> _ Vehicle License No. . <br /> Printed Name of Hauler Signature of mauler <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS: Ci ofManteca.W :I <br /> City QCF 2450 West Yosemite Ave. Manteca,•CA 95337 � <br /> I <br /> I certify that the bauIer above delivered the described liquid waste to this disposal 4w lity,and that it was <br /> accepted4rejected(circle one)material under the terms of the Receiving Station Pernik <br /> Signature 6f Waste Facility Operator <br /> DATE 4, TIME OUT NET QUANTITY 3�� s <br /> TIME IN , <br /> j <br /> Rev.02/09 office assist3 comms 1 <br /> z d �9 'oN AOS 0l S l0Z .9 �pW <br />