Laserfiche WebLink
CS � Loi, S61L "N AdO�:Z ti[OZ, '0E 'd;S awil paAl ;);d <br /> 1( l4q <br /> CITY OF MANTECA WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LIQUID WASTE ph <br /> (�2cq) <br /> NAME: �;jS� CS�.�L!/(�, PHONE: <br /> PICK-UP ADDRESS: 1ALD0 S v y"J" ed C' zed i r&;O; e-lti <br /> Number Street city State Zip <br /> WASTE SOURCE: DOMESTIC WASTERWATER ONLY from (Circle One): c Tan Portable Toilet <br /> PICK-UP DATE: / 7 TIME: /� QUANTITY: r 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 Owne O upant Agen <br /> 2. HAUL <br /> NAME: ) ,— <br /> BUSINESS ADDRESS: ��'7-r <br /> Number Street City State Zip <br /> I certify that the described waste was hauled by meto tf�e disposal facility named below. <br /> :52PrReceiving Station Permit No. f��- / vehicle License No. �7'3�1:52— <br /> Printed <br /> inted Name Of Hauler Signature of Hauler <br /> 3. RECEMNG 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 one)material under the terms of the Receiving station Permit. <br /> Signature O Waste Facility Operator <br /> DATE: TIME IN: tl •SJA- TIME OUT: NET QUANTITY: GALS. <br /> s <br /> Revised 10/17/12 <br /> V0/Z0 39Vd J=Od OlOJ 9Z6559V60Z ZV :2-Z VIOZ/02-/60 <br />