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L090 "N WdtiO :Z [ LIE 'S 'uer awl j P,Ala�ad <br /> crrX oE LECA wocF , <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LIQUID M AFU <br /> NAME! 5 �c� --�`Y/t�` _ PHONE �-97 _/ Z <br /> PICK-uPADDRESS_ f 2a �,6 <br /> Number Street City �- State zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): Septic Tank Portable Toilet <br /> PICK-UP DATE TIME / QUANTrI yaLs <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated. � <br /> Prhited Name of Owner,Oeenpant or Agent igBatare of Owner,Occapant or Agent <br /> I <br /> 2. AAi7T.F.R <br /> NAME &tQ R2= <br /> Bust ss ADDRESS AJ <br /> Number Street City stEM zip <br /> I certify that the descabad waste was hauled by me to the disposal ftc>7ity-named below. <br /> Receiving Station permit No. 2- Vehicle License <br /> GL41 �`✓ti <br /> Printed Nanie of Hauler signs <br /> tru-e of <br /> i <br /> 3. RECEIVII G STATION <br /> NAME AND ADDRESS: City ofMaateca WQCF 2450 West Yosemite Ave. Manteca,-CA 9533-7 I <br /> i <br /> I comfy that the hauler above delivemd the descnbed liquid waste to this disposal , d that it was <br /> accepted/rejected(circle one)mataual under the terms of the Receiving StitouP <br /> Siguature of Wasteykeffity Operator <br /> z I <br /> DATE //� �/ TTIv1E IN l� 3d MMOUT Q h 1 =QUANTITY <br /> Pzv.021o9 ofa=assa't t(famjS _ <br /> ,I <br /> d I6L9 "N &01 :ZI LIH 'S upr <br />