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G �8SS6 'ON 061 : E S�OZ 'das awil paniaOa� <br /> saw <br /> CITY OF MANTECA WOOF <br /> WASTE HAULER'S SOURCE CER.TUICATION <br /> Z. PRODUCER OF LIQUID'WASTE pg <br /> PICK UP ADDRESS <br /> Number Street City Ste zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY frons(circle one): J eptic T' Portable Toilet <br /> � <br /> i <br /> K K-UP DATE S'J Tl]�IE - 7 QUAN= <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated. <br /> Panted Name of OWner,Occupant o•Agebt S e of Owner',O npant ar rct <br /> 2. ULER <br /> NAME Roto R ter <br /> BUSINESS ADDRESS <br /> Number Street City State -Zip <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Receivin Station Permr <br /> it No. r"-2 r �' <br /> g _ l "� � Vehicle License No_ <br /> Printed Name of Hauler Sign2tare of R4uler <br /> 3. RECEI VIWTG S'T'ATION <br /> NAM?~ANDADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,.CA 95337 j <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility,and that it was <br /> accepted/reiected(circle one)waterial undczr the terms of the Receiving Stasi Per <br /> Sigh[✓Ore Of WaAe Facility Operator <br /> I7Ax$ �p <br /> TIM1r IIY Tll1QE OUT , rl NET QUANTI'T'Y� - 4313 <br /> • I <br /> Rev.02109 office assisbjWfv®s <br /> tid IzZPON AV[� :Ol SIOZ ll 'd;S <br />