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ti099 'IN WdLti: 1 til0Zy„9�l _�nr a,!1 paniaaad <br /> . I <br /> CITY OF MANTECA WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> PRODUCER OF UOUID WASTE PH O <br /> I <br /> 4E ase,6A JILL, P H 0 x L8-__3 I_1// <br /> I <br /> 1-uPAnD <br /> xEss `� S �� �:� ��ti �c � �i. <br /> Number Street city State Zip <br /> 3TE SOURCE: DOMESTIC WASTEWATER ONLY from(circle ono)- a tic Tan Portable'toilet <br /> .-UP DATE / ,�" TIl�E l U + I v QUANTITYI,?�` <br /> dfy that this waste was delivered to the hauler named below for legal disposal at the site indicated- <br /> ted <br /> ndicatedted Name o Owne3r,OccXLp t o Agent Signature of Owner,Occupant or Agent <br /> _ I <br /> HAULER <br /> � Ro R tPz <br /> i <br /> 1NBSSADDRESS Oyl Q S C 0� �Q <br /> Number Street City State Zip <br /> I <br /> tify that the described waste was hauled by me to the disposal facility named below. �/ i . <br /> riving Station permit No_ Vehicle License No_ 3 T"��-�- U3 1 <br /> ted Mame of Hauler Signature of Hauler <br /> RECEzMc S`arATION <br /> 2E AND ADDRESS: City of Manteca WQCl~ 2450 West Yosemite-Ave. Manteca,CA 95337 <br /> i <br /> Efy that the hauler above delivered the described liquid waste to this disposal facility,and that it was <br /> pted/irejected(circle one)material udder the terms of-the Receiving Station Permit t <br /> I <br /> Signatare of Waste p'acility Operator <br /> E 0 �✓ C�� DA IN ! V TUAE OUT NET QUA U Y I <br /> }i <br /> l <br /> I <br /> ' I <br /> )24office assimUfotms ^ <br /> } <br /> L0/Z0 �9�d �Diood 0101 9Z6559PG0Z TS :ZT PTK/9T/L0 <br />