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Z6L6 "N AO :01 SIN 'WIDO awil paniaa;� <br /> CITY OF MAMc.A,MCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PR__ODUCER QF LIQUIDWASTE �. <br /> PA <br /> NAME, S ° 1 qll <br /> PHONB ° <br /> PICK-UP ADDRESS­Z20, Cc%t �Cti r <br /> Number <br /> street <br /> City statezip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from <br /> (circle one): eptic Tank' Portable Toilet I <br /> PICK-UP DATE --/���� �,� . <br /> QUANTITY ��. talc <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated <br /> Printed Name of Owner,Occapaltt or Ag t tnr of O� <br /> It or Agent <br /> 2. HAULER <br /> NAME to R to <br /> BUSMSS ADDREsS � /lfpz S <br /> Number Street City Suite Zip <br /> I certify that the described waste was hauled by me to the disposal fac1hty named below. <br /> Receiving Station Permit No. Vehicle License No. <br /> Printed Name of Hauler Si�astare of Hauler <br /> 3. MC9nMLG ST TION <br /> NAME AND ADDRESS: City ofMalateca WQCF 2450 West Yosemite Ave. Manteca,-CA 95337 <br /> i <br /> I <br /> I certify that the hauler above delivered the descabed liquid waste to this disposal ;ty t it was <br /> accepted/rejected(ci r..le one)material under the terms of the Receiving Statio ' <br /> Z <br /> Signature of Waste Pscrlitp Operator <br /> DATE � <br /> Tr'M M TIME OUT � � � NET QUANTITY <br /> Rev-02/09 ace as5ist�t/fvcros <br /> I <br /> z 'd 06ti� A 0911 SM 'W110 <br />