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HL "N MSI :Z EIOZ '0 '�aa-,;WIJ p;AIaDa� <br /> qC 0 U\6 <br /> CITY OF MANTECA WOCF f <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1_ P O UC1iR OF LY UID WASTE pH <br /> i <br /> NAME PHONE,Z�I �O� <br /> PICK-UP ADDRESS 1_,edhf-O P <br /> Number Street City State Zip <br /> I <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle Q ptic Tack Portable Tollet <br /> PICk-UP DATE TIME %l QUANTITY als <br /> 1 certify that this waste was delivered to the hauler named below for legal disposal at the site indicated <br /> Printed Name of Owner,Oceppant or Agent Signature of Owner,O cu nor Ag t <br /> a. HAMUR <br /> NAA Roto Rooter <br /> BUSINESS ADDRESS �U Q '�� 1`j �A Jf'm.5_ <br /> Number Street City State Zip <br /> I certify that the described waste was hauled by me to the disposal facility named below- <br /> Receiving <br /> elowReceiving Station permit No. Vehicle License No- <br /> Printed Name of Hauler Signature of ffa—uler <br /> 3. RECEIVING 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 descn-bed liquid waste to this disposal£ac- tit w <br /> accepted/rejected(circle one)material under the terms of-the Receiving Station P <br /> Signature of Waste Facility Operator <br /> DATE I� 3 TIME IN / �U TIME OUT f � NET QUANTITY 3�� ga1s <br /> r - � <br /> Rev.02/00-office assiMndforn,s <br /> CT/00 39dd N3100a OlOa 9Z6SS9V60Z 9T:VT CT07,/0T/ZT <br />