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nc� S61L "N AdOti:Z ti[OZ '0E'd";"S�auiiv paAl ;);� <br /> M�oay �tJ141 <br /> CITY OF MANTECA WOOF _ <br /> WASTE HAULERS SOURCE CERTIFICATION <br /> DD <br /> 1. ODUCER OF LIQUID WASTE P h <br /> PR <br /> NAME: i S �(�Cc ' PHONE: <br /> PICK-UP ADDRESS: �. S, htG�d'��i> Y L- ? � / <br /> Number Street City State. Zip <br /> WASTE SOURCE: 9DOMESTIC WASTERWA'TER ONLY from (Circle One): optic Tan Portable Toilet <br /> PICK-UP DATE: / TIME: 'r � QUANTITY: J � <br /> 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 Slgna r of Owner, c pant 01T9ent <br /> 2. HHS <br /> NAME: 12o 4—(:::, v <br /> BUSINESS ADDRESS: y2,2r lVdC G LO-r\ <br /> Number Street City State Zip <br /> I certify that the described waste was hauled by me to he disposal facility named below. °7 <br /> Receiving Station Permit No. vehicle License No. / / J-2 <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 descfibed liquid waste to this disposal facility,and that it was accepted/ <br /> rejected(circle one)material under the terms of the ReceMi ng Station Permit. <br /> Signature Of Waste Facility Operator <br /> DATE: -23-I`� TIME IN: TIME OUT: NET QUANTITY: 73`�� GALS, <br /> 1b <br /> Revised 10/17/12 <br /> Y <br /> I <br /> VO/60 39Vd �Oioo�i OlO'I 9Z655976UZ Zb ET bTUZ/0 /60 <br />