Laserfiche WebLink
HOVIN W' E :E [ S106, 'Ol 'Gad ;Wli paA193;� <br /> CITY OF MANTECAA <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PLODUCER OF LIQUID WASTE ph <br /> NAME: ` se� .,a i ) r <br /> _ PHONE: �Gf <br /> PICK-UP ADDRESS: —/&-70 S L11 Z-'1i4 17C P Crl � J <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTERWATER ONLY from (Circle One): Portable Toilet <br /> PICK-UP DATE: ^�b' I _-_-- TIME: �r ' . �' 4'. ..-- -- QUANTITY: GALLONS <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the slte Indicate <br /> Printed Name Of Owner,Occupant Or Agent gnature Of Owner,OccUpant Or Agent <br /> 2. HAULER <br /> NAME: 240 - <br /> BUSINESS ADDRESS: ' '.r,.JCi►'tA' f,'�i �' �r` ` <br /> Number Street City state Zip <br /> I certify that the described waste was hauled by me toe disposal facility named below. _ �rG <br /> Receiving Station Permit No. _ �, Vehicle License No. T/ . <br /> Printed Name Of Mauler Signature of Hauler <br /> 3. RECEIVI.149_STATION <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 disposal facility,and that it wascce iced <br /> rejected(circle one)material under the terms of the Receiving Station Permit. <br /> Signature of waste Facility Operator <br /> DATE: '1-2b- TIME IN' kl}A[ TIME OUT: - NET QUANTITY: GALS. <br /> Revised 10/17/12 <br /> 9 'd ti«� 'ON Wb00 ll � �oz a� ,qac <br />