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666Z "N AHSO : OI EH '9 gaj ;W1j paniaaa� <br /> CrTY OT' <br /> - -- ELA'woc� <br /> WASTE HA•.ULER.'S SOURCE CERTIFICATION <br /> 1- PRODUCER OF LLQUM WASTE <br /> PH I <br /> PICK- ADDRESS <br /> Number Street City State 1P <br /> WAS SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): Septic Tank Pocrt�able Toilet <br /> PICK- DATE TIME ! QUANTITY V ala <br /> I c ; t this waste was delivered to the banlor named below for legal disposal at the site indicated. <br /> Priv Blue of Owner,Occupant or Agent S1knature of Owner,Occupant or Agent <br /> •I <br /> 2. ULE I <br /> NAME Roto R <br /> ll .; <br /> BUS S ADDRESS <br /> Number veet City tate Zip <br /> I certify t the desm-bed waste was hauled by me to the disposal facility named below_ <br /> Reed ' Station Permit No- Vehicle License No. Q� <br /> Pri atefl a of Wuler Signs of H� �r <br /> 2 <br /> 3- ENING STA ON <br /> NAME q1D ADDR$SS- <br /> City of Manteca WQCF 2450 West Yosemite Ave. Manteca,'CA 95337 <br /> I <br /> I certify tthe%miler above delivered the descri-bed liquid waste to this disposal facility,and that it was <br /> accept ejected(circle one)material under the terms of the Receiving Station Permit j <br /> Signature of;waste Facility Operator � <br /> BATE Q <br /> - <br /> 11vIE]N 1111 OUT NET UANTITY <br /> ,Roy-02/09 0 ' assista�/fa®s <br /> ti 'd 6EL6 'ON AVSI :OI 8102 9 gad <br />