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sr ooa ani aniaaa <br /> `a� ��cti ' N WdS l Z Boz �o [ ' a 1 P � <br /> P/ <br /> CITY OF MANTECA'V QCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LIOU>A WASTE pH 11::5� s <br /> NAM Ir ffJ77 �n�6c� (%�S )QPHONY 9�Q <br /> PICK-UP ADDRESS $U Sd 1 [JL e.te,/ AV <br /> Com. /sve-") <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one Septic Tank Portable Toilet <br /> PICK-UP BATEl �� TIME /�1`Soli QUANTIT als <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,Occupsut or Agent Signature of Owner,Occupant or Agent <br /> 2. HACTLEI <br /> NAA R t tez <br /> BUSINESS ADDRESS -rZ <br /> umber Street City State Zip <br /> I certify that the described waste was hauled b me to the disposal facility named below. �!a <br /> Receiving Station Permit No. �� — Vehicle License No- <br /> Sp <br /> 0 cT "1 <br /> s <br /> Printed Name of Hauler Signature of Hauler <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,CA 95337 <br /> 1 certify that the hauler above delivered the described liquid waste to tlJis disposal facility,and that it was <br /> aeeepted/rejected(circle one)material under the terms ofAhe Receiving Station Permit. <br /> � \ L <br /> Signature oY Waste Facility Operator <br /> DAVE -'Pk -13 TIME IN 0-'ADI TIME OUT NET QUANTITY_, O gals <br /> s <br /> Rev.02,'03 office assigta fb= <br /> ET/90 39VC1 �GiO J 0101 9Z6559b60Z 9T:bT ET0Z/0T/Z1 <br />