Laserfiche WebLink
8SS6 "N 061 :01 5106 ll 'das quail paniaaa� <br /> owe 7 � <br /> CITY OF MANTECA WQCF <br /> WASTE HAULER'S SOURCE GERTaIF'ICATION <br /> I. KR_0D1 CM_UF LIQI)ID WAS'I']E pH �'1 • ` + <br /> NAME G o �'_ Ct l.i�Gr PHONE <br /> PICK-UP ADDRESS /2030 5 __!L5 3 3FD <br /> Number Street City State z <br /> WASTE SOURCE,�DO�M DOMESTIC WASTEWATER ONLY from(circle one): c a_ portable'Toilet <br /> PICK-UP DATE_. % QUAMTrY <br /> I certify that this waste was delivered to the hauler named below for legal sal at the cite indicated, <br /> i <br /> Printed Name of Owne ,Occ' anti Agent Si tore a ercup$nt 4 Agent <br /> 1 <br /> 2. R <br /> NAME Roto Boater <br /> BUSINESS ADDF.ESS <br /> Num sheet city state zip <br /> I certify that the descnbcd waste was haiged by me to the disposal facility zoamed below. <br /> Receiving Station Permit Na. � Vehicle LicenseNo. <br /> Printed Name of l[anler Signatare of Hisider <br /> 3. RECLIVI NC I ATION . <br /> I <br /> NAME AND ADDRESS. City of Manteca WQCF 2450 West Yosemite Ave. Manteca,-CA. 95337 j <br /> I certify that the hauler above delivered the descrz'bed 1i waste to this sal fac <br /> accepted/rejected(circle one)material under the termso the Receiving Sa ou Perm' d tit was <br /> Ae_df Waste Facility Operator <br /> 72 <br /> DATE Cy Tr,4E IN -rm Our PNET QUANTITY gals <br /> Rev.02149 office assists fora <br /> 1 <br /> 'd [66� 'IN <br />