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116Z 'ON NOS : I 910 '9l 'ur aUJIi paniaaa�; <br /> � L <br /> CITY OF MAN'I'ECA.WOCF <br /> WASTE HAULER'S SO <br /> URC$ CERTIFICATION <br /> • i <br /> 1. PRODUCER QF LI WAS pA <br /> NAME;' CJD f�rG �G�SC'G%C� PHONE <br /> PICK- ADDRESS_ j D�i 7� S ,c���,n ��f G� r�0/✓ G�Gl- �S �j�I <br /> Number Street City State Zip <br /> WAM SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): Septic Tank Portable Toilet <br /> PICK- DATE- F-/S- °� IIM:E 57 <br /> QvANTTrY 8 � <br /> I certify t this waste delivered to a bawler named.below for legal dieposai at the site indicated. <br /> I <br /> �,I V�_ <br /> Prautedl ame of Owner,Occupor <br /> Agent Signature of er,Occupant or Agent i <br /> 2. I <br /> NAW!! Roto Rooter <br /> BUS S ADDRESS <br /> Number Strut City State <br /> zip <br /> 'a - <br /> I certify t the described waste was hauled by me to the disposal facility napped below_ <br /> Recei Station Permit No_ ` c� — Vehicle License No. <br /> Print eme of Hauler for of$ iuler <br /> s , <br /> 3• G SjAnON <br /> NAivIE ADDRESS_ City of Manteca WQCF 2450 West Yosemite Ave. Manteca,•CA 95337 <br /> I certify t the hauler above delivered the described liquid waste to this disposal facility,and that it was <br /> accept ejected(circle one)material under the terms of the Receiving Station P <br /> i <br /> Signa of Wast acMty Operator <br /> DATE Z` 7TE'M IN <br /> TII�OUT NET QUANTITY <br /> I <br /> RTV.02/0,9 o as Ystmt/lb�s <br /> �i <br /> ti 'd '' 0096 "N WdOO :z 21H 91 'u�r <br />