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'290 [ "N Wd�o : Z 9l0Z S un auJil paniaaa� <br /> CrTY—OF riANTECA WQCF <br /> WASTE HAULER'S SOURCE CER11FICAT'ION <br /> 1. Pl3ODUClM.01?LMM WASTL pH — <br /> NAME 1)0��� PHONE <br /> PICK-UP ADDRESS\aC�)L` <br /> r <br /> Neer Strutt City State zip <br /> WASTE SOURCE. DOMESTIC WASTEWATER ONLY from am): Septic Tank Portable TOM ' <br /> PICK-UP DATE-2~1 ~ (a TmM QUANMTY <br /> I certify tient tba waste was delivered to the hailer named below for legal disposal at the site <br /> �Prhded Name of Owner,OW%4m t or Agent $dust re of Ov►nar,Occupant or Agent <br /> 2 � <br /> BUSMESs ADDRESS �, .� tc�'1 'kc� 1 C, <br /> Number Strut City State zip <br /> I certify that the desmlled waste was hauled by me to the disposal facility=ed below. <br /> Receiving Station Permit No. Vehicle License No. <br /> i <br /> Printed Name Hailer taste of H4 <br /> i <br /> 3. N <br /> NAME AND ADDRESS: City of MmAcca WQCF 2450 Weal Yoemiite Ave. Manteca,-CA 95337 <br /> I certify that the hivalar*bow delivcred the dambed liquid w=ne to this dLM <br /> awt rt <br /> acreptedhrejecW{circle om)nil under the terms of the Receiving S <br /> Slgnatwe of aste Facali ty Operator , <br /> DATE`� 1�IL" Tnvs�IN T"ovT NET QUANTITY SS 19 s <br /> Rev.02'09 o$CO 1fcC= <br /> ti d ssc� 'oN WdSo z 9� In91Hnv <br />