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4 <br /> IZSC°N WdC� :E tiIOZ, II 'n 'aW11 P;A1 0 � <br /> CITY OF MANTECA MCF <br /> WASTE HAULER'S SOURCE CERT FICATION <br /> �- r9onuC�__ ___O L101xa WASTE p <br /> NAME �. .; ( <br /> PHONE +t I <br /> PICK-VP ADDRESS 2-4141-012 I <br /> Number Street — .46-33v <br /> ' <br /> City State zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): rVue - PortableToilet <br /> PICK UP DATE d ' � - TIME l -. ('� QUANTTI X <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated. <br /> ERE <br /> Fruited Name of Owner, ceupsat or' ent 'La--8ignatar of Owner,Ocenpaut Agent <br /> 2. HAULER <br /> NAME Roto R <br /> BUSINESS ADDRESS of ZA <br /> Number Street City State Zip <br /> I certify that the described waste was bawled by me to the disposal facility named below. <br /> Receiving Station Permit No-- Vehicle License No. 1-3 l� <br /> Printed Name of Ranier Siatnre of Haler <br /> I <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS: C"yof Maateca WQ <br /> CF 2450 West Yosemite Ave. Mauteca,.CA 95337 � <br /> I <br /> I certify that the hauler above delivered the descrg>ed liquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material tinder the terms of the Receiving Station Pernik <br /> Signature OMIste Facility Operator <br /> DATE li:,- „z_ TIME INti l� TIME OUT <br /> NET QUANTTTYals <br /> Rev_02/09 office aistat/fo= <br /> 'd l lH '°N Wdtiti til4Z l l 'MjN <br />