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669L 'IN WdH :: tiI0 l l 'aaa auiI J P9AIaaa� <br /> CITY OF MANTECA <br /> WASTE HAUL EWS SOURCE CERTIFICATION 40 <br /> f. PRODUCER OF LIQUID WASTE ph <br /> 114 <br /> NAME: f �.����� ,' �cG�� PHONS2� <br /> PICK-UP ADDRESS: <br /> Number Street City _ tate Zip <br /> WASTE SOURCE: DOMESTIC WASTERWATER ONLY from (Circle One): eptic Tank Portable Toilet <br /> PICK-UP DATE: _ I`I % '_ 7" TIME: QUANTITY: �: G� GALLONS <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated. <br /> Printed Name Of Owner,Occupant Or Agent Signature Of Owner,Occupant Or Agent <br /> 2. HAULER <br /> NAME: <br /> BUSINESS ADDRESS: <br /> Number Street City State Zip <br /> I.cerkify khat 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 Hauler <br /> 3, RECEIVING STATION <br /> NAME AND ADDRESS: City Of Manteca WQCF 2450 W. Yosemite Avenue, Manteca, CA 95337 <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility,and that it was accepted/ <br /> rejected(circle ane)material under the terms of the Receiving Station Permit. <br /> Signature Of Waste Facility Operator <br /> DATE: -11116 1 TIME IN: 12'.2a. &,v TIME OUT: 1NET QUANTITY: moo--4-60 GALS. <br /> Revised 10/17/12 <br /> Z 'd LOLO 'ON Wdlc l tiIOZ l l 'aa(l <br />