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DWON &6E :1 L10 E 'A awil paniaaa� <br /> 3u43 v <br /> CITYOFNAMCAWOCF <br /> WASTE HAIJLER'S SOURCE CERTIFICATION <br /> L PRODUCER Og LI UID WASTE PH <br /> PICK-UP ADDRESS /�/J3C� S ��Q19�1J A�/ L' c� <br /> Number Street City State Ztp <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): S tic Portable Toilet <br /> PICK-UP BATE %.� / 7 TIME QUANTI _Z <br /> I certify that this waste was delivered to the hauler n=ued below for legal at the site indicated <br /> Printed Name of Owner,Occupant air Agent S e of Owner,Occupant or Aunt <br /> 2- HAULER <br /> NAME Roto RDoter <br /> i <br /> BUSINESS ADDRESS_ v2 "' �UGUr✓ ,4G S ��o.�� t �'Number Street City State Zip <br /> I certify that the descn7xd waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No. - Vehicle Lice=No 7::?— <br /> Printed <br /> 2Printed Name of Hauler Sif( tare of Hauler <br /> 2 - <br /> 3. STAT1 <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 WestYosrmite Ave. N auteca,-CA 95337 <br /> I certify that tbe%auler above delivered the des,- ' ligmd waste to this disposal facility,and that it was <br /> accepted/rejected(cazle one)M=erial under the terms of the Receiving tion Permit <br /> i <br /> S tore ante Facility Operator <br /> i <br /> DATE TAvIE IN `L� h Mf$OUT NET QUANT�5 <br /> Rev-02/09 Office-Sisk furors <br /> 'I <br /> ti d LLSL "N ME : l LIN 'E ��W <br />