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12tiO "N Md :S 9102 Zl '�aa ;will p;ni ;a;E <br /> Homo <br /> CITX OF MANTECA W CF <br /> WASTE HAULBR'S SOURCE CERTIFICATION <br /> !. PR DUCER QF LIQUID WASn ' <br /> PH <br /> NAME ' �- �►'►'�c�t 5 � /� `� <br /> PHONE 9K ' <br /> PICK-UP ADDRESS Number Street city zip Z p%,:�� <br /> State ---�� <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLy from(circle one): Septic Tank Portable Toilet <br /> PICK-UP DATED ✓C TIME ,,j ` QUANTTI`Y .0'�' pais <br /> I ei� that this waste was delivered to the hauler named below for legal at the site indicate& <br /> Printed Name of Qwner,Occupant or Agent afir��o Owner,Od�' r�¢a <br /> 'U I <br /> 2. RAVLE <br /> NAME oto Rooter <br /> BUSINESS ADDRESS <br /> Number Street City State Zip <br /> I terrify that the described waste was hauled b me to the disposal fatality named below. <br /> Receiving Static%Permit No. Vehicle License No. 6 <br /> hVN <br /> Printed Naate $Haler <br /> Signature of i <br /> I <br /> 3• RWEMING STATION <br /> NAME AND ADDRESS- City of Manteca WQCF 2450 West yosemi Ave. Manteca, <br /> .CA 95337 <br /> I certify that the hauler above delivered the desm--bed liquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material und,=-the terms of the Receiving Station Permit <br /> S �eof Waste Facility Operator <br /> DATE ILLO <br /> 2 <br /> TIME LN Zoe"i TIIvM OUT NET QUANTITY <br /> v <br /> i <br /> 'I <br /> Rev.02/09 a£6cc assist=Vfvru s <br /> z 'd ZZ99 'ON Wdz� : s 9 �H z � ;a <br />