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EKG( fes, ti099 'ON WdLti l til0Z '9l '[1r 1WIJ paniaaa� <br /> �.M CITY OF MANTECA W CF <br /> WASTE HAULER'S SOURCE CERTIFICATION . <br /> i <br /> kRODUCKE,OF LY4UID OVASTEPHO <br /> -UP ADDREss lX 36 Ueu le-ii rW -1e t1-o c- 93" <br /> I <br /> Number Street City Fn Sta Zip <br /> 5TE SOURCE: DOMESTIC WASTEWATER ONLY fxom(circle one) Septic Tan Portable Toilet <br /> -CTP DATE ;o � QUANTITY_ �� gals II <br /> tify that this waste was delivered to the hauler named below for legal7 osal a e s' ated, 4 <br /> • I <br /> ted Name of Owner,Occapant or Agent <br /> PULER . <br /> Row Rooter /J i <br /> INESS ADDRESS n <1( yZ ' i <br /> eA- <br /> Number Street City state Zip <br /> ti£y that the described waste was hauled by me to the disposal facility named below. 07 <br /> ,iving Station Permit No. � Vehicle Liceuse No.7r 7_Lv`�p <br /> ted NaLme of Hauler Signature of�[a <br /> RECEDING STATION j <br /> I <br /> dE AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,CA. 95337 I <br /> t the hauler above delivered the described liquid waste to this disposal ty and that it was j <br /> pte ejected(circle one)material under the terms of4he Receiving Station P t i <br /> - Si nature of aste facility Operator <br /> T Co' 1 4—TWE IN TIME OUT J NET Q'UANTTrY ✓�3 gals <br /> • i <br /> I <br /> N ! <br /> { <br /> )21Uzlofi5ce assi�randtbcros � I <br /> I <br /> LO/90 �cJ7d �IE10ON 0101 9Z6559b60Z T9:ZT VTOZ/9T/L0 <br />