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o1 � awi aniaaa <br /> Zti�B ' N WdLO �Z S l OZ 'L l ° W_ 1 p �; <br /> { <br /> CTTY OF <br /> MANnCA WQa <br /> WASTEHAULER'S SOURCE CERTIEICAT70N <br /> 1. JjAER_QF LfOUTA WASTE PH---:zC <br /> NAME -S C--A i PHONE <br /> PICK-UP ADDRESS C. �/`c: . G��J� r:-.r.'r �,-� Z '�'�d{ .� �•, <br /> Number street City Stag zip <br /> WASTE SOiJRCE: DOMESTIC WASTEWATER ONLY kom(circle one): Sep fC ank'', PortabU Toilet <br /> PICK UP DATE . <br /> -;� 1 TIME ` QUANTITY T' ' <br /> I certify that this waste was delivered to the hagler nmed below for legal disposal at the site indicated. <br /> Printed Nxm of Owner oftupintor Agent Sig�aatture of owner,Occt u�. <br /> 2. <br /> NAME $� <br /> BUSDIESSS ADDRESS <br /> Number Street City State Zip <br /> I certify dW the deacrtbed waste was hauled by me to the disposal&c,-aty named below. <br /> Receiving Station Permit No. I Vehicle License No. '7-/- 6`;.5 <br /> n <br /> Printed Name of Hauler %patature of Hou* <br /> 3. RFAZJ�STATION <br /> NAME AND ADDRESS: City ofMaMteca WQCF 2454 West Yosemite Ave. Ma ,,CA 95337 <br /> I certify that the hauler above delivered the described hggmd waste to this disposal facility,and that it was <br /> aeeeptedfrejected(circle one)material under the terms of the] viog Station Permit <br /> Signature of Waate Facility Operator <br /> DATE T TXME IN (�f TIME OUT l��� NET QUANTITX ��gals <br /> Rev.02/09 off=znjg� <br /> z 'd RLI 'ON M60 :6 SAN 'Ll "PN <br />