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rn <br />ce) <br />00 <br />to <br />00 <br />0 <br />0 <br />C <br />M 0 <br />M 4- <br />cB <br />0) U <br />M <br />U N <br />CU <br />a) U <br />0 <br />O <br />c Q) <br />crrY oh MANTECA WQCF <br />WASTE IIAULER'S SOURCE CERTIFICATION <br />1. PRODUCER Of LIQUID WASTE q r <br />PHONf� <br />NAME �✓,y w /dLl 1/�n�_�GCm �G%/OQ� . �•�� _q G� <br />lip <br />PICK-UP ADDRESS <br />Number Street City <br />WASTE <br />ESSOUR _CE: DOMESTIC WAS TEWA"rERONLY from(circle one): <br />Septic Tank ) Portable Toilet Other (describe)5� _gals <br />I— QUANTITY <br />PICK -UPDATE —2 I TIMI <br />I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated. <br />Printed Name of OIN Fier, Occupan gent Signature of Owner, t or Agent <br />Occupan <br />Z. HAULER <br />NAME United Site Services <br />Modesto CA 95357 <br />Roscow Road State Zip <br />Number <br />BUSINESS ADDRESS Street City <br />Number <br />I certify that the described waste was hauled by me to the disposal facility named below." <br />Vehicle License No <br />Receiving Station Pemtit No.—P-21 — / <br />C/Signature of Hauler <br />i <br />Print Name of I{nuler <br />3" HE;CE;lVING STATION <br />• E AND ADDRESS: City o1� Manteca W(?CF 2450 West Yosemite Ave., Manteca, CA 9533' <br />NAht <br />material under the terms cif the Receivi e tati m Permit. <br />I certify that the hauler above delivered the described liquid waste to this disposal facility, and t tat rt titan <br />accepted/rejected (circle o+7e) <br />Signature of Waste Facility Operator <br />Print Name of Waste Facility Operator <br />--NET QUANTITY r SD6 gals <br />/ T1r__ <br />DAhk IME I <br />� - <br />Rr+. p? (I++ ollicc assi,lanUseptic deliacries and dala <br />CV <br />4 <br />tll <br />tT <br />M <br />a_ <br />