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6909 '°N WdH :E tiI0 ;W1J pania);� <br /> CITY OF M.ANTECA.WOCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> L PRODCJCER OF LIQUID WASTE pH <br /> NAME I 1 r � S(' c l PHONF2a`' � <br /> PICK-UP ADDRESS 12 2an �'. J4,a�-&,t1 Lr, "r-nio C91 /S-,33Q <br /> Number Street City State Zip <br /> WASTE SOURCE: D10WVIC WASTEWATER ON-LY from(circle one eptle Tank Portabll�e Toilet <br /> PICK-UP BATE /I / I - TIlv1E f Q �5 QC7ANTITYS',C gals <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated, <br /> Printed Name of Owner,Occupant or Agent Signature of cups t r Agent <br /> 2. HAULER <br /> NAA— t o <br /> BUSINESS ADDRESS IV, ,Ler, lod S��-r, ell, <br /> Number Street City State Zip <br /> I certify that the described waste was hauled by me to the disposal facility named below, � �/j�p�pp�� <br /> Receiving Station Permit No. a Vahiele License r�No. /73ro / LD <br /> Printed Name of Hauler Signature of Hauler, <br /> 3_ RECEPVING STATION <br /> NAME AND ADDRESS: City of Manteca'W'QCF 2450 Nest Yosemite Ave. Manteca,CA 95337 <br /> I certify that the hauler above delivered the desen`bed liquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material under the terms of-the Receiving Station permit. <br /> Signature of Waste Facility Operator <br /> DATE A q-\ei TIME]N �V5 TIME OUT NET QUANTITY .L✓teals <br /> Rev.02/0§*office assis[aaitt/fomis <br /> 50/Z0 �J�d 'J3100a 0101 9Z6559b60Z bZ:VT bTOZ/5T/50 <br />