Laserfiche WebLink
��Lti '�N WdSI Z E 06 '0[ '3;a awil paAI;3;� f <br /> o � a� <br /> CITY.OI~ h11AN7t=GA WaCP , <br /> W_A$'LE HAU'_ER'S SOURCE CERTIFICATION <br /> Rev. 3/04 <br /> 1. PRODUCER OF LIQUID-V1(��TE <br /> i <br /> f <br /> PICKUP ADDRESS_ 7?5d C � � 5326 <br /> Number Street 'city 13 State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from (circle on9); Septic Tank Portable TDllet <br /> PICK-UP LATE_ l \ — M 1_3 ,TIME _ 36 QUANTITY gals <br /> I <br /> I certify that this waste was delivered a tha hauler named below for legal disposal at the site indloated. <br /> i <br /> Printed Name-of Owner,Occupant or Agent Signaturq Of Owner,Occupant or Agent <br /> 2. HAULER <br /> NAME <br /> BUSINESS AODRESS_ 2 Q <br /> Number Street City state Zip { <br /> } i <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> ReceNinq Station Permit No, IG��17 Vehjrin, I Ir-Anco Mc •� �'L( t <br /> Printed Name of Hauler Signature of Haulor, <br /> 3• RECEIVING STATION 1 <br /> NAME AND ADDRESS; city of Manteca WQCF 2450 West YDSeriift:Ave. Manteca, 95337 <br /> I carnry tmr ine hsulor abovo dollvorad the described N01 wi-Alp. II; III, r„kilily, AVId Thal it ✓vas <br /> accepted/rejected (circle one) material under the terms of the Receiving Station Permit, <br /> �Sianature of Waste Facility Operator <br /> DATE Wt i TIME. IN TIME OUT NET QUANTITY 3 Z013 els_ <br /> i <br /> 2 3S 3�y <br /> 6T/ZT 39dd N310ON OlO�i 9Z6559b60Z 9T:bT ETOZ/01/ZT <br />