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N08 'ON AVIl :: l S10Z '0l 'gad ;aril pania0a� <br /> CIT"OF MANTECA„WUCF 00.� t <br /> WASTE HAVLER'S SOURC CERTIFT 'ATTQN <br /> 1. FRt0MTCER OF LIQUID'WASTE Pg <br /> NAME 3 <br /> i <br /> PICK-UP ADDRESS k-1 <br /> NumberStxeet r <br /> Criy State zip- , <br /> i <br /> WASTE SO G'B: DOTMST'I WAS ATER ONLY from(circleWE=SepficTa��' Portable Toilet <br /> PIG'I-UPATE <br /> ` TME �, QUANTITY <br /> I certify thatti vered to the hauler named below for legal disposal at the site i7pidlCa#e4, <br /> Plin <br /> ted Nsaxe of Owner,Occupant or Agent 'Signature of Owner,Occupant o—Agent <br /> 2. RATTLER <br /> NAML Kqto Rooter <br /> BUSINESS ADDRESS 9Number <br /> city State Zip <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station PexmitNo. ` — Vehicle License No. <br /> P � <br /> Cx7:1 ' t <br /> Prlated Name of Hauler of IRMit <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS: Ci of Manteca W <br /> ty QCF 2450 West Yosemite Ave. Mantecs,.CA 95337 <br /> I <br /> I certify that the hauler above delivered file desmbed liquid waste to dais disp e” ,and fiat it was <br /> sccepted/rejeeted(circle one)material =the terms of the Receiving Statian <br /> Sigpature of W to acyl- Operator <br /> DATE 1Z'I TIIVIE rrr I 2�1_TTME OUT .GO wl NET QUANTITY/;, <br /> i <br /> i <br /> Rev.02M9 office assistC[tlfonz <br /> Z 'd ticr� 'ON '0� 'gad <br />