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02,24/2094 08:49 2t759252385cTTY E129 '°N=N 90 Z tiIOZ Zl '2nyPamil pania�a� <br /> SOURCECiTY OF MANTECA—WC)CP -- 005/7 <br /> E ICATION * <br /> Rev.3/00 <br /> I. PRODUCER OF LH2U ID WASTE <br /> NAME jo►S C/.c�G PRIONS — <br /> P ICK.UP ADDRESS a U O �GL�l�✓� L��r � 33U <br /> Number Street City state Zip <br /> WASTE SOURCE: DOMESTIC VlASTEWATER ONLY from (cirde one); ptiC Ton Portable Tollet <br /> PICK-UP CAT / TIME t1UANTITYcl gals <br /> I ce(tify that this waste was delivered to the hauler(lamed below for legal dlspO821 at the site indl ed. �71f rD' V <br /> MJL_Q� <br /> Printed Name of owner,Occupant or Agent sig ura of Ownec <br /> Cicupant I <br /> Age <br /> 2. HAVLE <br /> NAME �L> <br /> BUSINESS ADDRESSa PA <br /> Number Street City State Zip <br /> I cerllfy that the described Waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No. / Vehicle License No. <br /> Printed Name of Hauler Signature of aulor, <br /> 3. REQFIVJN!9 STATION- <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 Weat Yosemite Ave. Manteca, 95337 <br /> I comrymm lno hsulor above dellverad the described 1kxH wa„KlM In ilith illnln+.,nl rmlily, Aod Ihal it Waa <br /> accepted/rejected (circle one)material under the terms of the Receiving Station Permit. <br /> 1 <br /> signatu tie of Waste Faced' Operator <br /> DATE 7 ! J bG )�--TIME IN Jo,i ) AK TCMF-ouT j.Q t ,7 ) AAM NET QUANTITY '� pais. <br /> 50/80 3Jtid �I3100�:1 0101 9Z6559b60Z 80:8T bTOZ/ZT/80 <br />