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'ON d [ r ` pZ�V ;Q ;WIJ paniaaa� <br /> CITY OF MANTECA WOOF <br /> WASTE HAULER'S SOURCE CERTIFICATION � � �/0 �0 <br /> 1. PRODUCER OF LIQUID WASTE pId <br /> NAMERn-,,Se PHO" <br /> PICK-UP ADDRESS <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from <br /> � (circle Septic Tank Portable Toilet <br /> PICK-UP DATE �� S I.3 TIME / .�y QUANTITY ahs <br /> I certify that this waste was delivered to the hauler named below for legal disposal a site indicated_ <br /> Printed Name of Owner,Occppant or Agent SignaiVe of Owner,Oe up n or Age <br /> 2. HAULER <br /> NAA <br /> trr <br /> BUSINESS ADDRESS ��D <br /> Number Street City- State Zip <br /> f <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No- — / Vehicle License No_ <br /> Mac 2 �Y�46 AL:: <br /> Printed Name of Hauler Signature of Harder <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 described ligWd waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material under the terms of-the Receiving Station Permit- <br /> Signature of Waste)Facility Operator <br /> DATE k�-s-1�> TEVIE IN 1l. TIME OUT NET QUANTITY 3gals <br /> . t <br /> a <br /> Rev.02/Wo'ficcessis=/fmms <br /> CT/C0 39tid z13100�1 0101 9716599b60Z 9T:bT CTOZ/0T/ZT <br />