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`6909 'IN Id06 :E 06 SI 'A au I pania0aa <br /> . CITY OF MAN-rECA wacP �� <br /> W g Q FR'S$ URC�ERTIFICATION <br /> Rev. 3ma <br /> 1. PRODUCER OF 101-1I0 WASTE <br /> NAME 1h��e `\t� sy��� 1�y� ( PHONE <br /> 3,6 <br /> PICK-UP ADDRESS ���'� t it�11'an c G� � C `15 <br /> Number Street Cit? State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY frorn (circle on3): Septic Tink Portable Tollet <br /> PICK-UP CAT - � r � � �TIMc10 ,Is_IA,n, <br /> QUANTITY d gals <br /> I certify that tnis wasts was delivered t,the hauler names tielaw for legal disposal at the site indicated. <br /> r <br /> Printed NameM Owner, Occupant or gent Signatufa Of Owner,Occupant or Agent <br /> 2. HAVLE <br /> NAME- --= a � <br /> BUSINESS AODRESs,-�)� — <br /> Number 5+feet City state Zip <br /> I certify that the described waste was hauled by me to the dispoSal facility gamed below. <br /> 1 ' <br /> Receivinq Statlon Permit No.—cl� 1 Vanir.lP' I ir.Rr�P. plc, .3c �_ _ <br /> Printed Name of Hauter Signature of Hauler, <br /> 1 RECEIVING STATION. <br /> 4 , <br /> NAIVE AND ADDRESS: City of Manteca WQCF 2450 West Yosemlte Ave- Manteca, 95337 <br /> i earnry int ine hs;uler Abovii dvllvvrW th;? dvscrlbed 1baO( wif'ily Ili I11-1 rlki ii I ATM Ihbl i1 Y33 <br /> accepted/rejected (circle one)material under the terms of the: Receiving Station Permit. <br /> � /�i,e e, - - <br /> Signature of Waste Facility Operator <br /> DATE TIME IN //, ZOr xl TIMI-OUT NET QUANTITY-?,-�60�gals. <br /> 50/50 39dd �OiOOa OiOd 9Z6559760Z bZ :bT bTOZ/5T/90 <br />