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ti888 '°N WH80 :6 8lOZ �ady wail pzniaaa� <br /> - I I <br /> CITY OF AL4NTECA W CF <br /> WASTE HAULER'S SOURCE CERTIPICATI0�1 <br /> 1. PRODUCER OF LIOUID WASTE pg <br /> NAME CAS C-6,ckz PHONE aoc::l. g 0,3 u ) i <br /> PICK-UP ADDRESS Z 3 C <br /> Number Street City ttate Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): Septic Tank Portable Toilet <br /> PICK-UP DATE f22 . 7 D 1 0 TIME e�j QUANTITY gals <br /> T certify that this waste was delivered to the TIME <br /> named below for legal disposal at the site in ' <br /> Pr' ted Na e o caner,Occupant or Agent Si ure of ctrp=1 or <br /> 2. HAULER <br /> NAME R to Rooter <br /> BUSINESS ADDRESS L42,ZS nt.t, ,l Qe-t fit,, S+DcJ4+6e1 G/� 9 SaaSJ. <br /> Number Street City State Zip <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station permit No. Vehicle License No. <br /> Printed Name of Hauler Qiature of Ha er <br /> 3. RECEIVI.NGSTATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,CA 95337 <br /> I 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 Permit. <br /> Signature o Waste Facility Operator <br /> 22 l� 3C) <br /> TIME.OUTDATE TIME NET QUANTITY s <br /> Rev.02/09 office assisrandfonns <br /> 5 'd 6266 '°N AVS . : 6 EH '6 'add <br />