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S6It 'IN Ado Z til0l 'OE 'd;S& il- p;AIa0 1 <br /> CITY OF MANTECI4 W CF <br /> WASTE MAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LIQUID WASTF- ph <br /> NAME PH9 :yJ <br /> PICK-UP ADDRESS: <br /> Number Street City _ State Zip <br /> WASTE SOURCE: DOMESTIC WASTERWATER ONLY from (Circle One): ptiic Tank Portable Toilet <br /> PICKUP DATE: TIME: Q <br /> o��/ / G V UANTM: ZZ GALLONS <br /> I certify that this waste w s deNi Bred to the hauler named below for legal disposal at the site indicated. <br /> Printed Name Of Owner,Occupant Or Agent Signature of owner cc pant Agent <br /> 2. HHA ULER <br /> NAME: a[ -n � <br /> BUSYNESS 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. 2 Vehicle License No. <br /> i <br /> Printed Name of Hauler Signature Of Hauler <br /> 3, RECEIVING NATION_ <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 W. Yosemite Avenue, Manteca, CA 95337 <br /> I certlfy 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. c <br /> qn Facility ra or <br /> DATE: TIME IN: TIME OUT: NET QUANTITY: GALS. <br /> Revised 10/17/12 <br /> b0/b0 :]Jyd iJ=0Z1 0101 9ZG999VGOZ Zb :ET VTOZ/06/60 <br />