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L090 "N Wdti0 :Z1 L1R 'S 'uir ;Wli paniaD;a <br /> CM OF MA-NTECA WOCF AV <br /> of <br /> WASTE MAULER'S SOURCE CERTIFICATION VA � 1 <br /> 1. PRODUCER OF LIQUID WASTE pH <br /> NAME D© , 12 I'. �` PRONE�2�'�J <br /> PICK-UP ADDRESS iJP pocS LA7kcd <br /> Number Street City State Zi�J <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): Septic Tank Portable Toilet <br /> PICK-UP DATE /Z l `'71 lC' TIME 3, /I QUANTI'I"Y-Z� � 'teals <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated. <br /> fir` ?�av-e__ <br /> P ` ted Name of Owner,Occupant or Agent Signat a of Owner,Occupant or Agent <br /> 2. HAULER <br /> NAME Rato.Rooter <br /> BUSINESS ADDRESS 7�� _ �_ ��4� 6. `�✓ <br /> Number Street, City State Zip <br /> I certify that the described waste was hauled by Jme to the disposal facility named below- <br /> Receiving Station Permit No- Z� / Vebicle LicenseecL ki LA—,No. <br /> r <br /> PrWted Nale of Hauler Signature of 1 f <br /> 3. RECEXYIN,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 liquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material under the terms of the Receiving Station Pe4Was <br /> it <br /> Sign acility Operator <br /> DATEL TIl�IN V� TIIvlE OUT �i J (�' NET QUANTITY <br /> kev.02!09 office assis=t/fo= <br /> S d 16L9 "N Ad01 Zl LZ S upr <br />