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NOVIN AV[� : k SI0Z . 'O [ ,pj auiil paA ] aaa� <br /> CITY OF MANTECA <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> i, PRODUCER OF LIQUID WASTE ph r <br /> NAME: ., 'i u ,C PHONE: <br /> PICK-UP ADDRESS: / i' /9 i- <br /> Number Street City �_ Zip <br /> WASTE SOURCE: DOMESTIC WASTERWATER ONLY from (Circle One): Septic Tank ) Portable Toilet <br /> PICK-UP DATE: :2�2TIME: r QUA GALLONS <br /> I certify that this waste was deiivered to the hauler named below for legal disposal at the site indicated. <br /> Printed Name Of Owner,Occupant Or Agent Signature Of Owner,Occupant Or Agent <br /> 2,. HAULER <br /> NAME: <br /> BUSINESS ADDRESS: 1� �.c �y LIQ <br /> Number Street City State Zip <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No. Vehicle License No. � � <br /> Printed Name Of Hauler Signature Of Hauler <br /> 3, RECEIVING 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 wa_ accepted/ <br /> rejected(circle one)material under the terms of the Receiving Station Permit. <br /> Signature Of Wask 1I1ty perator <br /> DATE: �' '/ TIME IN: U 7Z _HME OJT: `-' NET QUANTLTY: �0 GALS- <br /> Revised 10/17/1,2 <br /> d tiC� l 'ON NVEE : l l S 10� '0[ ,pj <br />