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02/24/23E1,4 08:49 2x098252.-155 CITY MC k1AV,.TC--A i.nrcper. ' R1 <br /> 8189 �N-1Nd90 Z til0Z Zl '�nd ;W!i paAianad <br /> CITY aF MAN'r_E_ W CP <br /> �nreq • HAUS ER'S SQUBCF CERTIFIP_Aj_L <br /> QN <br /> M • gas <br /> Rev. 3100 <br /> 1. PROQUCER OF [aUlO wa�T� i <br /> NAME t XJ f PHONE / ✓��Z rJ�J `' <br /> PICK 12y� J t1C.t� r1 �1'f�;� /• 1� � <br /> Number Street City state ZIP <br /> WASTE SOURCE: DOMESTICWASTEWATER ONLY from (eirde one); Septic Tank rta-ble Tollet <br /> PICK-UP GAT TIME QUANTITY �3;7u 1 gals <br /> I certify that tils wasta was delivered to the hauler named below for legal disposal at the site indicated. <br /> Printed Name of owner,Occupant or Agent 5ignatura of 77 <br /> Ccupa or Agent <br /> 2. HAUL.E.R <br /> NAME <br /> BUSINESS ADDRESS <br /> Number Street City $tate Zip <br /> I certify that the described waste was hauled by me to tde disposal facility named below. <br /> ReCblving Station Permit NO.,,,, <br /> f Vehicle License No,2ZS <br /> i <br /> Printed Name of Hauler signature of Haulse, <br /> 3. REGEfV1NQ§TATIQN <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosernhe Ave. Manteca, 95337 <br /> I cernry tnst ino haulor above dellvvrvd thit descrlbe<31!<kllil wa-ite IIS ;1k1-1 MMI whnl fmkAly, at-III lhat II wax <br /> accelrted/rejected(cirde one)materia{under the terms of the Rec Iving Station Permit. <br /> _ G <br /> _�Jd_ <br /> Signature of Waste Faciliiy Operator <br /> DATE TIME IN L 35 12 AA TIME OUT_J.' S5 D NET QUANTITY__jy3.LZ__g81s. <br /> 5e/5e ��Jvd N]i0od oioii 9z69G9b60Z 80:6T 17TOZ/ZT/80 <br />