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�ELti 'ON WdSI :Z E10�'O�l 'v�wil pania0a� <br /> tU <br /> CITY OF MANTECA WOCF <br /> WASTE HAULER'S SOURCE CERTIFICATION M Q I <br /> L PRODUCER OF LI UID W E Ii <br /> P <br /> NAME_ ISS C ,SCCi��P PHONE f,3 <br /> PICK-UPADDRESS <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTZWATER ONLY from(circle one): a tic Ta Portable Toilet <br /> PICK-UP bAT-E—&ii-L/-3 - <br /> QUANTITY__;F6 6___gals <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,Occupant or Agent Signa o Owner,Occuba6t or Age <br /> 2. HAULER <br /> NAlV Rato&gtrr I <br /> BUSRMSS ADDRESS_ �c�,c <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 Station Permit No. / 'Vehicle License No. <br /> moo- <br /> Printed Name of Hauler Signature of Haul r <br /> 3. RECEIVING STAT ON <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 under the terms okhe Receiving Station Permit. <br /> Signature 6fWaste Facility Operator <br /> DATE �k-5.1 TYME IN TIME OUT NET QUANTITY 3 aLoJ gals <br /> Rev.02i00'oIffiee assi=ndfonns <br /> ET/Z0 39dd �3iOMJ OiO�I 9Z6559b60Z 9T:VT ETOZ/0T/ZT <br />