Laserfiche WebLink
Z6L6 "N W E :01 SIH '�l 'Jl0 awil PaAl ;); ' <br /> OF MANTECA WOCF ..•� /�t/ <br /> WASTE HAULER'S SOURCE CERTTICATION <br /> 7• PRODUCER QZLIQUID WASTE PH <br /> NAME 1 PHONE o o <br /> PICK-UP ADDRESS <br /> Number <br /> Street City Stats Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): 'c Tank Portable Toilet <br /> PICK-UP DAT$ /�—/.j .j-Qy¢ QUAN-= d - <br /> I certify that this w srte-%w delivered to the hauler named below for legal disposal at the site indicatecL <br /> Fretted Flame of Owner,OcarpA or Agent S' of or,Ocrap ent <br /> NAME Rom Rooter <br /> BUSINESS ADDRESS_4Q a y <br /> Number Street City State Zip <br /> I certify that the descril>ed waste was hauled by me to the disposal Faci]ity named below. <br /> Receiving Station Permit No. �oC ( Vehicle License No. �... <br /> Printed Name of R uler - <br /> Signstnxe of puler <br /> 3_ RECEIVINGSIADoN <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave, Manteca,CA 95337 <br /> I certify that the hauler above delivered the described waste m this <br /> ace ted/r 'erted h disposal fwility,and that it was <br /> ep tj (circle one)material under the terms of-the Receiving Station Permit <br /> Signature of Waste Faaj ty for <br /> DATE U C nNM IN TIME OUT NET QUANTITY gals <br /> i <br /> ' I <br /> Rzv.02!09 office ass�srmt/fomes <br /> ti 'd 06tiE "N NM : Ol SIH 'til 'il0 <br />