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2808 '°N AV[B : ll SIH '0l 'gaj awil pania3;� <br /> �) yIZ- <br /> O OF_MANTECA WUCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. )'RODU OF O _ W.ASTE pH - <br /> NAME 6yl r�- -nr L ��� ,,�. PHONE v t �� l <br /> PICK-UP ADDRESS i\� <br /> Nxunber Street City State Zip <br /> i <br /> WAS'T'E 80i7RCE: DOMESTIC WASTEWATER ONLY from(circle one): Septic T Portable Toilet <br /> PTCK-up DATE �7 <br /> QUANITrY � staLs <br /> I certify that this waste was delivered to the h=kr umed below far legal disposal at the site indicated. <br /> Frhl"N �cr,0=paut er Agent Signature o�ek,Occupant or Agent <br /> 2. <br /> NAME Ro1n Roatrr <br /> susll ms AmmsY.2 ' la Ci 7— <br /> Numbcr sweet qty sta,o , zip <br /> I certify that the dc=ftocd waste was hauled by me to the disposal facility z=ed below. <br /> Rexty mg Station 1'eamit No.�� } - _ _ Vehicle Lice.No.-7-FX;, <br /> Printed Name of hauler Signunre of X4uler <br /> 3. RECELV_11 -Q S &UW <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,.CA 95337 <br /> I cx*that the hauler above delivered the described hgmd wasW to oris&V osal facility,and that it was <br /> accepted/iejecte d(circle one)material ender the terms of the Rec4ivizig Station Pemt. <br /> Signature 6f Waste p'le ty Operator <br /> DATE s t ^� TIME IN Ck`tom TIME OUT NET QUANTITY_'t <br /> Rev.42/09 ofce ssi0mWforme <br /> 8 'd tiLP 'CN WdtiB l l S106 0l 'gad <br />