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6266 '0N AV0ti 8 S Z 'A0N auij pania0a� <br /> T�4t ] <br /> CITY OF MANTECA W-OU <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> I. PRODUCER OF LIQUID WAsTE pH <br /> NAME D►S e PHONE& <br /> PICK-UP ADDRESS LAL-L a &,Aedp e1c 5�87,? <br /> Number Street City State Zip <br /> WASTE SOURCE: DONeSTIC WASTEWATER ONLY fromcirc : <br /> le one): <br /> ) �PdCT <br /> Portable Toilet <br /> Pick-UPDATE ��`�� �� TIME Q <br /> QUANTITY � <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicared_ <br /> I <br /> :I <br /> Printed Name of OwnOctup `tor Agent S tare of Owner, <br /> panto aril <br /> Z. <br /> NAME R ter - <br /> BUSINESS ADDRESS 2 2 Al", <br /> Number street city Stan zip <br /> I certify that the des�wash was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No. � 1/ Vehicle License No. ,`� <br /> Printed Name of Hauler <br /> Signature of Haler <br /> 3. G 8 ON <br /> NAME AND ADDRESS: Ci of Manteca.DV ! <br /> ty QCF 2450 West Yosemite Ave. Manteca,.CA 95337 � <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material under the terms of the Receiving Station P <br /> � r <br /> Signataxe okWaste F ty Operator <br /> DATE - S T rVM IN TRAE OITI 1 NET QUANTITY � �� als <br /> Rcv.02/09 ofuce as /fMMS <br /> t d ME '0N NV 9 S 0 z 'AIN <br />