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Z909 'ON WdH :E tiI0 'S 'A awil paniaa; <br /> y <br /> CITY OF MANTECA WOCF <br /> WASTE HAULLR'S SOURCE CERTIFICATION <br /> i. PROAUCER OF LIQUID 1VASTE pH <br /> NAME <br /> PICK-UP ADDRESS <br /> Number Street City State Zip <br /> WASTE SOURCE: DO ST WASTEWATER ONLY from(circle one): eptzc a Portable Toilet <br /> PICK-TTP DATE / TIME ,� QUANTITY a3 als <br /> I certify that this waste was delivered to the hauler named below for legal dispo at the site indicated, <br /> Printed Name of owner,Oceppant or Agent Signature of Owner, cc ant or ent <br /> 2. gAULER <br /> N.A R -to Rootf-r <br /> BUSINESS ADDRESS �/V,�?e 11/ x4)�o vk- <br /> umber Street City State Zip <br /> I certify that the described waste was hauled by me to the disposal facility named below_ �j�' <br /> Receiving Station Permit No. � (/ Vehicle License No. / ( <br /> Zosewel ft-66r-'C' <br /> Printed Name of Hauler Signature of Hauler <br /> 3. RECEWING STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,CA 95337 <br /> 1 certify that the hauler above delivered the described liquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material under the terms of-the Receiving Station Pe 't. <br /> rgnature of Waste Facility Operator <br /> DATE ` TIME]N Z j O p TIME OUT 3 NET QUANTITY lI L gals <br /> Rev.02/0ffice assigtant/forms <br /> 50/50 39Vd �i=Od 0101 9Z6959b60Z bZ:PT bTOZ/5T/50 <br />