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o ��°" �� ", a awl aniaaa a <br /> zsas ' �d�1� 0� 'q 1 P <br /> rrY OF MAN'' CA,WOCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> I. PROIDUCEIt OF MOM WASTF H r <br /> P <br /> Lnlse. <br /> NAME C L— PHONE D 1 fJ el- 11 <br /> PICK-UP A17DRESSy 1�i � , � - i ��ti771�-vi �t 7---, 33z:�) I <br /> Number StreetCity State zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): tic d ank.� Portable Toilet <br /> PICK-UP DATE L �� -1 TDAE �3QUANTITY �' gals <br /> I certify that this a was delivered to the hauler lwmed below for IL-94 disposal at the uda'catecZ�� <br /> Pitted N� e e Owner,Occupant or Agent �rSar' rjDccApant or Agee <br /> Z. � I <br /> HAQ ER <br /> BUSINESS ADDRESS <br /> Number Street qty State lip <br /> I certify that the desciibcd waste was hauled by me to the disposal faeflity named below. <br /> Receiving Station Permit No.�� ' l Vehicle <br /> ,. License <br /> Printed Name of Hauler <br /> Siglmture of 94nler <br /> 3. RECEIVING STATION <br /> NANS AND ADDRESS: City OfMantw-a WQCF 2450 West Yosemite Ave. ManteM CA 95337 f <br /> I <br /> I certify that the hauler above delivered the described liquid waste to this&Tosal <br /> ecce te&re'ected fl6lity,and that it was <br /> P J (ale one)material under the terms of the Reeeivzrtg Station Permit. <br /> Signature WWaste Facility Operator <br /> DATE 1 - =IN TZIVE OUT NET QYJANTIT'Y:-- �OC� gals <br /> - I <br /> i <br /> Rev.02/09 office assist, t fomes <br /> 'd �L� [ 'ON <br />