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Zti88 '�N WdLO :Z SIOZ 'LI 'JPW awil P;V ;3ad <br /> CITY OF MANTECA <br /> sum owl <br /> WASTE H&JUR'S SOURCE CERTIFICATION <br /> 1. pH J <br /> NAME_ "�j C C r`' `. C,'i. d ;k _. PHONEE <br /> PICK-UP ADDRESS Jr� ' ; <br /> Number Stncet City State Zip <br /> WAS'T'E SOURCE: DOMES'TIC.WASTEWATER ONLYfrom(circle one): Septic Tank Portnbk Tom <br /> PICK-UP DATE QUANTITY -5 , L frals <br /> I certifg&d "vwam eves delivered to the hmkr named below for legal disposal at tbo;site indicate& <br /> Name of 09mer,Urccap=t or Agent S af"ORaer,OecgpW or Agent <br /> LIZ <br /> 2. HAULER <br /> NAME R,otn RQober _ ' <br /> BUSWESSADDRESS - fav Wtom, lr, iC;\t CIA <br /> J <br /> Number Street City State Zip <br /> I comfy that the dmml)cd waste was hauled by me to the disposal facility=mud belov <br /> r � <br /> Iteoeiviag Station Permit No.� � Vehicle License No / / ,�� S�� <br /> Printed Name of Haller ire of 9,01er I; <br /> 3. R VIl G STATION <br /> NAME AND ADDRESS: City cf Manb=WQCT 2450 West Yosemite Ave. Maatma,.CA 95337 <br /> I c4rtify that the hauler above delivered the decd lulmd waste to this disposal facility,md that it was <br /> semptedfrejected(circle one)material wader the terms of the Reemvmg Statxm Ntcwit. <br /> ,5*16tare of Waste :cMq Operator <br /> Nati <br /> DATE _o' TIME IN ,� TII OUI �r " QUANTITY <br /> Rev.02/09 office xwjvmVk= <br /> ti d BLL [ 'ON 10Z 'Ll 'a �W <br />