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L090 "N WdtO : Z [ LIH 'S 'upr ;W1j paniaa;a <br /> :i <br /> CITY OF MANTECA W CF <br /> :1 <br /> WASTE HAULER'S SOURCE CERWICATUON <br /> L PRODUCER OF LY UH)W—AISTX pH <br /> NAME U /'S CSS PHONE <br /> PICK-UP ADDRESS /)-6SO ,1-5 (fJCga� L,A r / <br /> Number Street City State zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): Septic Tank Portable Toilet <br /> PICK-UP]SATE 1 ` �� TIME - � C QuANTrrY <br /> I certify that this waste was de "vered to the hauler named below for legal dispo the sitte indica <br /> Name of Own er,Occupant 3r Agent tnre of Owner,Occupant or Agent <br /> i <br /> 2. HAY.JLEIZ i <br /> i <br /> NAME Xp <br /> tQ_Rooter <br /> I <br /> BUSINESS ADD"Ss <br /> Number Street City State Zap <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No. 77( Vehicle License <br /> Printed Nanie of Hauler <br /> Signature of g4ul <br /> ,1L_ <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,-CA 95337 <br /> the hauler above delivered the described,liquid waste to this disposal and that it was <br /> (f!zccept ejected(circle one)material under the terms of the Receiving Station P t <br /> i <br /> Signature of W Facility Operator <br /> DATE �� ✓rIItilE IN �'�7 wt X`B�OUT /ttl NET QUANTTI Y <br /> -T----- � QaLs <br /> Rc�.02/09 oface assS.staiYt/fo= <br /> �l <br /> d 16L9 "N WdE : z [ LIN 'S 'Upr <br />