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------ N"MSI i pania�a� <br /> CITY OF MANTECA WQCF moa 3 6 <br /> WASTF.HAU` EFZ'S SOURCE C RTIFICATION <br /> Rev. 3/CO <br /> 1. PRODUCER OF U01110 W YE <br /> NAMEy`�'�'�a �r�`A C ca S 1 )Q:J PNONir <br /> PICK-UP ADDRESS_ _ �� <br /> Number Street City Stste Zip <br /> WASTE SOURCE- DOMESTIC WASTEWATER ONLY from (cirde one): Septic Tank Portable Toilet <br /> r <br /> PICK-UP DATE_ 1 ,TIME QUANTITY gats <br /> 1 certify that this waste was delivered Z,tha hauler nam--d below for legal disposal at the site indlcated. <br /> Printed Name of Owner, Occupant or Agent Signatura of Owner,Occupant or Agent <br /> 2. HAULER ` <br /> NAME <br /> BUSINESS ACORESS �`' <br /> Number treet City State Zip <br /> I certify that the described waste was hauled by me to the disposal facjAy named below. <br /> Recelvina Station Permit No._ v VehiN4' I i�pn�a�1n _ <br /> Printed Name of Hauler signature of Hauler, <br /> 3. RECEIVING ST,ATIQN <br /> NAME AND A00RESS; City of Manteca WQCF 2460 Wast Yosemtt:Ave. Manteca, 95337 <br /> t carnry rnz Ino hsular above delivered thii described Ikjkl4l w:,,Ir Ir I11ti kIkIni,Hl tmAly,A,rd lhal l was <br /> acceptedfrejected (circle one)material under the terms of the Receiving Station Permit. <br /> Signature of Waste Facility Operator <br /> DATE TIMI; IN L '.a TIME O:1T NET QUANTITY OGJ gals_ <br /> 2 <br /> 6T/6T 39dd i'=0�1 0101 9Z6S99b60Z 9T :bT 6TOZ/0T/ZT <br />