Laserfiche WebLink
L090 "N WdtiO : Z [ LIH S 'UPr ;WWI paniaD"low ex <br /> a� <br /> -� CITY OF X ANTECA WQCF <br /> WASTE MAULER'S SOURCECERIMC.A.TION <br /> 1. PRODUCER OF LIQUID WASTE <br /> NAME .Gori -�e_ _C,,�, _&c o�d,9. _ PITONS C d j 7�_-, <br /> PICK-UP ADDRESS /'Z Q,'3 O .50 HA j/Q.v L 0-, Lr�4 f es`Pe.. C'_ <br /> Number Street City State Zi <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): Septic Wank Portable Toilet <br /> PICK-UP DATE / l TIl�IE G QUANT __ <br /> I certify that this waste was delivered to the hauler named below for legalsal at the site indicated. <br /> ted Name of Owner, ccnpant or Agent Sl�a of Owner,Oceap3nt or Agent , <br /> 2 HIMMAR <br /> NAMER outer <br /> BUSINESS ADDRESSC-a- <br /> Number Street City State Zip <br /> I certify that the desmbed waste was hauled by me to the disposal facility named below. <br /> ' SReceiving Station Permit No. � Vehicle License Noi,,��� <br /> Privated N.Me Of of Rauler — - - — -- Signature of ftnuligr <br /> 3. R9CEK9NG ST T QL <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 west Yosemite Ave. Manteca,-CA 95337 <br /> I certify that the hauler above delivered the descn'bed liquid waste to this disposai facility, and that it was <br /> accepted/rejected(circle one)mauerial under the ins of the Receiving Station Permit. <br /> a of Waste Facility Operator <br /> DATE < 2- %`�6 TRJE IN 1G_5_�: TZ-M OUT—///✓y N-ET QUANTM,- , 6 <br /> ECEIVE <br /> JAN 0 5 2017 <br /> tom.02/09 office asAys fofmNVIRU-NMEN��HATH <br /> P . <br /> `RMIT/SERVICES <br /> z 'd �6L9 "N WdU : z [ LIH 'S u�r <br />