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- o'N.:MSI Z .n`�I0 '0 'baa awFl -paniaaad <br /> CITY OF MAN: ECA WQS3 F <br /> 1N_ ASTF. HAUJE R S SOURCE CERTIFICATION <br /> Rev. 3100 <br /> 1. PRODUCER OF LIQUID W TE <br /> 1 1'� <br /> NAME_ a:i SQ A� lJ ofc-'—pHONE <br /> PICK-UP ADDRESSZ_�y <br /> Number Street City State zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from (circle ons); Septic 72YA Portable Tollet <br /> PICK-UP CIATE_ \ O`� 1 _ TIMEc QUANTITY a � gals <br /> I certify that this waste was delivered z ,the hauler nam-ad below for legal disposal at the site indloeted, <br /> Printed Name of Owner, Occupant or Agent Signatura or Owner,Occupant or Agent <br /> 2. HAULER <br /> NAMEa �o <br /> BUSINESS ADDRESS <br /> Number Street City State Zip <br /> I cirtify that the described waste was hauled by me to the disposal faculty named below. <br /> or <br /> Recelvinq Station Permit No. _ ` � � Veni�!� I ir.an�A Mn <br /> Printed Name of Hauler Signature of Hauler, <br /> 3. <br /> RECEIVING SYATION <br /> NAVE AND ADDRESS: City of MaMaca WQCF 2450 We3t Yosernfts Ave. Manteca, 95337 <br /> I earnry m:.t lne hsulor ebovv dellversd the described 1401 w:+ar Iii liItirn%Zly, Arld that it was <br /> accepted/rejected (circle one) materiat under the terms of the Receiving Statlon Perm?t. <br /> Signature of Waste Facility Operator <br /> DATE Il.gyp-1 TIME IN Tlti1f= OUT NET .:lUANTITY 3,200 dale i <br /> 230 3 <br /> 6'/60 3!DVJ d3100N 0101 9'655917607 9T:VT 6T0Z/0T/ZT <br />