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----- M 'IN'� I :C-5'�-['0 'Ol '�aQ awil paAIa0a� <br /> CITY OS MAI`JTE=CA W<5CP2-8 <br /> D <br /> WAS HO�I„1'_ER'S SOURCE CERTIFICATION <br /> Rev. 3/CO <br /> 1. PRoaUCER oP iJQUIQ WASTE <br /> NAM PHONE <br /> i <br /> PICK-UP ADDRESS 1 <br /> Number Street City, 5 zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from (circle ors): Septic Tank Portable Tol!et <br /> PICK-UP OATF- TIME 7? QUANTITY gals <br /> I cartify that t)is waste was delivered: the hauler named below for legal disposal at the site indloeted_ <br /> Printed Name of wner, Ocxligant or Agent "YSignatura of Ownar, Occupant or Agent i <br /> 2. HRUL ER <br /> NAMENJ <br /> . <br /> BUSINESS ADDRESS <br /> Number inset ity State zrp <br /> e <br /> I c:Mfy that the described waste was hauled by me to tile disposal facility named below, <br /> Recef%Anq Station Permit No VertiN�'I inPn�a Fin_ <br /> tint d Name of Vaulgr 5ignatur>r lar, ` <br /> �. ! GglYINQ STATION <br /> " NAME AND .ADDRESS: City of Manteca WQGF 24SO Weat Yosemite Ave. Manteca, 95337 <br /> I corm/mat ino hsuliar abovo dollverad the d�scrlbetJ IUau�l w:+ar !,; I,h III-in-Hf in��lily• �„,��Ihal it was <br /> accepted/rejected ; <br />