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AdLE :� tiI06 'll 'AoN awil paAI ;3;� <br /> CITY OF MANTEC,A WOOF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LIQUID WAUE ph _ <br /> NAME: a 1 sJ`.-rl /—"4ITe, PHONE: _2 <br /> PICK-UP ADDRESS: S- Oin;o%1 d /°'/it vi�,, ak. <br /> Number Street City .. Zip <br /> WASTE SOURCE. DOMESTIC WASTERWATER ONLY from (Circle One - Se is Portable Toilet <br /> PICK-UPDATE: 10 -;21-1'9" TIME: QUANTITY: �C I � 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 certify that the described waste was hauled by_-me to the disposal facility named below. <br /> Receiving Station Permit No. ' ` Vehicle License No- 7 j�! � <br /> Printed Name Of Hauler Signature Of Hauler <br /> RECEIVING STATION <br /> NAME AND ADDRESS: City Of Manteca WQCF 2454 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 one)material under the terms of the Receiving Station Permit. <br /> Signature aWaste Facility Operator <br /> QUANT <br /> TIME OUT: 0 j NETITY: GALS.U <br /> DATE: ti0-.ii-�� TIME IN: V.�,�._� J <br /> Revised 10/17/12 <br /> Z 'd l IR 'ON 'AoN <br />