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`HLti "N�WdSI ZE 0 '0l °aaQ aWIipaniaaa� <br /> CITY OF MANTECA WQGP Q o {1 <br /> WASTEFIAW PER'S SOURCE CERTIFICATIPN <br /> Rev. 3100 <br /> 1. PRODUCER OF LIQUIO_W,AUF— <br /> NAME '''1Y' \"��� C�C > PHONE <br /> 45PICK-UP ADDRESS 2 <br /> Number Street City 5teta Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from (circle one): Septic rank Portable Toilet <br /> PICK-UP GA1'5_�,-„. � �2 ,TIME QUANTITY6a gals <br /> I certify that t)is waste was delivered t, the hauler narne'd below for legal disposal at the site Indicated. <br /> Printed Name of Owner,Occupant or Agent 5ignaturo or owner,Occupant or Agent <br /> 2. HAWLER <br /> NAME <br /> _ s � a� <br /> BUSINESS AC7DF2ESS <br /> Number Street City State :dip <br /> I certify that the described waste was hauled by me to Me disposal `acidly named below. <br /> Recelvinq Station Permit No._� V2'? � I i;cAnee 14^_w <br /> rinteQ Name' <br /> o Hauler �at aular, <br /> 3. RECEIVINQ STATION <br /> NAVE ANO AODRESS: City of Manteca WQCF 24S01,1/est Yosemlts Ave. Manteca, 85337 <br /> I cornrym2t in hr.ulgr 9bovg dollvorad th@ 05Crlbed IV-10I w;�,lr !I1 lib kll,lai,;iI fhselilY. rind Ihdl iI Alas <br /> acceptedlrejected (circle one) material urdec the terms of the Receiving Station Permit. <br /> Signature of Waste Facility Operator <br /> DATE// TIME IN f TIME OUT NET QUANTITY 37D,'ocD oats. <br /> 036331 <br /> ET/0T 39dd d=021 01021 9Z6559b60Z 9T:bT ET0Z/0T/ZT <br />