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SEWON AVSZl E 0 S 'A0N aW paA1 0 <br /> CITY OF MANTECA WOOF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRQAUCER OF LIQUID WASTE pH <br /> NAME D .5�, C � �� PHONg�6 9. /�-T y <br /> 'r n <br /> PICK-UP ADDRESS U-7y <br /> Number Street City , State Zip <br /> • :I <br /> WASTE SOURCE- DOMESTIC WASTEWATER ONLY from(circle one Portable Tollet <br /> PICK-UP DATE ry TIME �, ha)VL QUANTITY gals ;l <br /> I certify that this waste was -vered to the hauler named below for legal disposal at the site indicated. <br /> • i <br /> Printed Name of Owner,Oceppaut or Agent Signature of er,Oce u r A.ge <br /> 2. HAULER <br /> NAI Roto Ro2pM ( 1 q <br /> BUSINESS ADDRESSNumber Street Street City State Zip <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> s�J773 LA- - <br /> Receiving Station Permit No_ a�^ Vehicle J_.ieense No. . <br /> Printed Name of Hauler Signature of Hauler i <br /> I <br /> 3. RECEYVING STATION <br /> I <br /> I <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,CA 95337 <br /> 1 at the hauler above delivered the described liquid waste to this disposal faci ' ,and it was <br /> accepte ected(circle one)material under the terms of�fhe Receiving Station P- t. <br /> Signature of Waste Operator <br /> DATE/9�''JJ <br /> 7_I TIME IN��-I�`,w TIME OUT J NET QUANTITY 5� gals <br /> .. I <br /> Rev.02/0'office assimi/forms <br /> - I <br /> 170/Z0 39tid a3100N 0101 9ZG999680Z 9Z:80 £TOZ/90/11 <br />