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E[99 "N M90 :Z tiI0 Zl '2nd aW!1 paniaaa� <br /> [A- <br /> CITY OF MANTECA WOCF 24, �7/n <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> PRODUCER OJF LWUID WASTE pH <br /> IE 16.(e d7V1,Ys�G.! . ��o�.l��l` PHONE 73 <br /> -UP AADREss_ J 2��� S • -��la., d2� L�� �o ci 3�c� <br /> Number Street City State z- <br /> 3TE SOURCE: DOj,IESTIC,W/ASTEWATER ONLY from <br /> (crcle one): Septic Tank Portable Toilet <br /> -UP DATE Y - rIlvIE �/�� QUANTrl-Y /baa ahs <br /> ey that Llys waste was delivered to the hauler named below for legal disposal at the site indicated. <br /> W Name of Owner,Occapant or Agent Signa a of Owner,Occupaik or Agent <br /> HAULER <br /> INESS ADDRESS ' <br /> Number�/ 'e i,66� � � ,� CCS <br /> 5 <br /> Street city State zip <br /> tify that the described waste was hauled by me to the disposal facility named below_ / <br /> ziving Station Permit No. %� ' 'V'ehicle License No. 74 Q <br /> r y <br /> ted Name of Hauler Signature of Hauler <br /> RECEIVING STATION <br /> 2E AND ADDRESS: City of Manteca WQCI' 2450 West Yosemite'Ave. Manteca,CA 95337 <br /> ti£y that Lhe hauler above delivered the described liquid waste to this disposal facility,and it was <br /> pted/rejected(circle one)material under the terms okhe Receiving Station P. <br /> Signature of Waste.FaciliqbperatQr <br /> E T]112E N , f� N'1 TIME OUT ; y�/s1 NET QUANTITY ��VV gals <br /> a <br /> )JO�oPfice assignni/forms <br /> 50/Z0 �9dd 2J=Oa 0101 9Z6559b60Z 20:ET 7TK/ZT/30 <br />