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8811 'IN Wd609 [0 'da sani l paniaoa <br /> � <br /> CTTY OF MANTECA WQQ &Mq <br /> WASTE HAULER'S SOURCE CER=ICATION <br /> 1. PRODUCER OF LIOUID WASTE p$ <br /> —(:o <br /> NAME . G b; �� / i es M ONE <br /> PICK-UP ADDRESS ��i �`s A; c I-ca` :;r,3 <br /> L <br /> Nu6ba Sheet City �� State Zip . <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY atom(circle one): Septic Tanis Portable Tweet <br /> PICK-UP DATE — (Q TIME l " L QUAN 1'1TY Z O b <br /> I certify the:this waste was delivered to the hauler named below for legs]disposal at the site mdicated <br /> i <br /> 1, <br /> Pri-n-&d Name of Owner,Occupant or AgentWI- 06re of Owue r,Ommpaut or'Agent <br /> NAME Rooter <br /> 1 <br /> BUSINESS ADDRESS L� M. �-i�"A, <br /> ' Shoe.: City State zip <br /> I catify tbat the desmilmd wane was hailed d by me to the du oral fac7ity named below. <br /> Reedving Station Permit No. Vehicle Liaease No. <br /> Printed Name of tare of H=alo <br /> 3. RFCRIM4G STATION <br /> NAME AND ADDRESS-. City ofMant=WQCF 2450 West Yosemite Avv. Mantma,,CA 95337 <br /> I crsffy that the haukc above delivered the dc=g)ed hgmd waste to this disposal facility,and that it was <br /> sceapW/rejeetsd(c=cle one)material mid=the terms of the Remvmg Sets m Pea= / <br /> o�W Fadiity Operator <br /> DATE: mm IN J"� 1 TIME OUT NE f QUANTITY <br /> Rey.OZ09 office <br /> s 'd 5565 'ON 9[0z 'daS <br />