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ti099 'ON WdLti: l ti[H 91 rJ@W"Ii"pania5; <br /> • i <br /> CITY OF MANTECA WOCF <br /> WASTE I-iAULER'S SOURCE CERTIFICATION <br /> i <br /> I <br /> I <br /> PRODUCER Off'LIOM WASTE PH <br /> I <br /> IE <br /> t 7 PHONEjo�� <br /> -UP ADDRESStla!'�U.h � ro <br /> Number Street City State zip <br /> 3TE SOURCE: DOMESTIC WAS NATER ONLY fxom(circle one)' -eptic T Portable Toilet <br /> / TIME 1 J 2 <br /> ,-UP DATE QUANTITY T�� <br /> gals <br /> tify that this was delivered to the hauler named below for legal disposal at the site indicated <br /> - I <br /> I <br /> ted N of Owner,Occ pan or Agent IgnatutCe of Owner,Occupant or Agent i <br /> HAULER <br /> Roto Root-°r <br /> rn-ESS ADDRESS <br /> Number Street City State Zip <br /> tify that the descnbed waste was hauled by me to the disposal facility named below. <br /> giving Station Permit No. Vehicle License No <br /> i <br /> 8,1")f - <br /> ted Name of Hauler Signature of Ha <br /> RECEDM TA O <br /> i <br /> 4E AND ADDRESS: City of Manteca WQCF 2450 West Yosemite-Ave. Manteca,CA 95337 <br /> ffy that the hauler above delivered the desenbed liquid waste to this disposal fa ' that it was <br /> pte&iejected(circle one)maternal under the teams of-the Receiving Station P. -t � <br /> i <br /> i <br /> Signature of Waste Facility Operat <br /> i <br /> lr� �� �'�/ Il�IE IN / C� TIME OUT NET QUAN I ITY <br /> I <br /> II <br /> i <br /> � I <br /> )2iO3'office assistanVfonns ^ <br /> 2�g� -1° f <br /> r <br /> L0/c0 �9�Jd �J=Oa 010 1 9Z6559b69Z T5:ZT 17TK/9T/L0 <br />