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. 8850 '°N WdBS �L 910Z _ 'Sl ''a�lN awi � pane a�a� <br /> CITY OF MLANTFCA WOCF <br /> WASTE HAULF-R'S SOURC G RT�ICATIniv <br /> L PRODUCER OF LI UED WASTE <br /> PK---7- <br /> NA Er 7r� : �` . ` ' _ PIi4NE <br /> PICK UP ADDRESS •' r/' <br /> Number Street City State dip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one), Septic Tank Portable Toni t <br /> PICK-TIP DAZE TIME � ��' � QUANTITY rcalG�_,. <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indi <br /> Printed Name of 0Z Qccupant or Agent Signature of Own e , ccupant or Agent <br /> Z. HAULER <br /> NAME at <br /> BUSINESS ADDRESS <br /> Number Sheet City State zip <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Rcceiving Station Permit No. Vehicle I icense No--� 4E / <br /> Muted Nanle of Hauler Signature of H�' <br /> 3. RECEIVLNG STATION <br /> NAME AN-D ADDRESS: City of 1vlatztecaWQCTC 2450 West Yosemite Ave. Manteca,CA 95337 <br /> 1 certify that the hauler above delivered the described liquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle oue)material under the terms of the Receiving Station F Ut. <br /> r <br /> 8i iiure ofWaste'Fae ity Operator <br /> 1 <br /> 5 <br /> DATE i ' % i' TIME N "1��TwE OUT NET QUANTITY J :' gals <br /> Rev-02J09 office assistam/forms <br /> Z 'd t 19� '°N 000 :8 91H S1 'a �N <br />