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H66 '°N WdOtil SZ 'Z 'noN a��il panizaz� .I <br /> CITY OF MANTECA W CF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. <br /> PRODUCER OF LIQUID WASTE pH <br /> AME $ <br /> N C L <br /> PHONE[24q �e3—0/y <br /> Plcx-Yrn ADD"Ss�20 <br /> NumberStreet City State <br /> Zip <br /> WASTE SOURC]E: DOMESTIC WASTEWATER ONLY from(circle one)- c T Portsble Toilet <br /> PICK-UP DATE__ l � TIlg_z �, -�S Q'TANTITY zals <br /> I certify that this waste was delivered tO the hauler named below for legal disposal at the site indicate <br /> Printed Name of Owner,Occupant or ent Signa a of Owner,OcItant or Ajent <br /> 2. HLMLM <br /> NAME Rotn R <br /> BUSINESS ADDRESS <br /> Number Street City State Zip <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No. Vehicle License2C()�pw) 6 No. <br /> r e, <br /> Printed Name of Hauler <br /> Signstare of Haler . <br /> 3. f <br /> ' 17VINQ STATIONi <br /> NAME AND ADDRESS. City of Manteca WQCF 2450 West Yosemite Ave_ Manteca,.CA 95337 <br /> I <br /> I certify that the hauler above delivered the desc -bed liquid waste to this disposal fa,,hty,and that it was <br /> accepted/rejected(circle one)material under the terms of the Receiving Statio ermit. <br /> i <br /> I <br /> Sia of a acuity Operator <br /> DATE � ��� <br /> '- —Tzm IlN—�z I S' TIlm QUT NET QUANTITY <br /> t Rev.02/09 ofEce azistanvfanas <br /> 'I <br /> 'd M '°N WH : 2 SAH z °N <br />