Laserfiche WebLink
NU "N AVl� : ll S10 '0l 'gaj ;W1J paAl ;D;� <br /> r cc <br /> CITY OF MANTECA <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LIOUI_D_WASTE ph _ <br /> I ' <br /> NAME: i li ( 'HONE: Q� <br /> PICK-UP ADDRESS: � �.��)- ��GLt"�Gz✓1 L�����fGi� T �°�_ r�?�� <br /> Number Street City ---SL?te zip <br /> WASTE SOURCE: DOMESTIC WASTERWATER ONLY from (Circle One): IC Ta�ly Portable TO[iat <br /> PICK-UP DATE: ( r�C ~I� TIME, /P'5'5 QUANTP Y; ALLONS <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicate <br /> Printed Name Of Owner,occupant Or Agent Signature Of Owner,Occupant Or Agent <br /> 2. HAULER <br /> NAME: r <br /> BUSINESS ADDRESS: <br /> Number Street City State Zip <br /> I certify that the described waste was hauled by me Co the disposal facility named below. r <br /> Receiving Station Permit No. 7)) Vehicle License No. I <br /> Printed Nance Of Hauler Signature Of Hauler <br /> 3. RECEMNG NATION <br /> NAME AND ADDRESS: City Of Manteca WQCF 2450 W. Yosemite Avenue, Manteca, CA 95337 <br /> i certify that the hauler above delivered the described liquid waste to this dlsposal facility, and that it was acre t <br /> rejected(circle one)material under the terms of the Receiving Station Permit. <br /> Signature Of Waste Facility Operator <br /> DATE; '1"� t`5 TIME IN: �v�_ TIME OUT: NET QUANTITY: ,r GALS. <br /> Revised 10/17/12 <br /> L 'd tiL� l "N AO : l M1 O l 'q;j <br />