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ULti "N WdSI :Z E10Z '0 [ 'O;a awil paniaaadL&14 <br /> ' <br /> CM OF MANTECA,W CF <br /> WASTE MAULER'S SOURCE CERTIFICATION <br /> i <br /> 1. PRODUCER OF LIQUID WASTE p <br /> NAME,4,L t r 0j- �d S L bP�!�,I b - PI-10N" �l <br /> PICK-UP ADDRESSJZZ,505LL,4,1" /LWV <br /> Number Street (City State Zip <br /> WASTE SOURCE: DO STIC WASTEWATER ONLY from(circ ): ptic Tank Portable Toilet <br /> PICK-UP DATE A TT1V1E ( J QUANTITY-42 Sals <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,Occppant or Agent Signature of Owner,Occupant or Agent � <br /> 2. HAULER <br /> NAIL Rot Rooter f <br /> BUSINESS ADDRESS {r�►1. C S <br /> umber Street City State Zip <br /> I certify that the described waste was ha��ujjled by me to the disposal facility named below. <br /> j� p <br /> Receiving Station Permit No. o� / Vchicle License No,-- T/ / <br /> Printed Name-of Hauler Signature of Hauler <br /> 3. RECEY•VING STATION <br /> NAME AND.ADDRESS- City of Manteca WQCF 2450 West Yosemite Ave. Manteca,CA 95337 <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material wader the terms okhe Receiving Station Permit. <br /> Signature oT Waste Facility Operator <br /> DATE V�- 13 TIME IN1 .a- TIME OUT NET QUANTITY Z2Q2 gals <br /> ,3 <br /> Rev.02/00'office as*tandforms <br /> 8T/80 EJbd �J=Od 0101 9ZG999b60Z 9T:bT ETK/0T/ZT <br />