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66H "N 0SVE EH 9 qac awll pznlaaz� .� <br /> D�loo- U 10 <br /> crrY of 1►rAlv�-E��,,wocF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODI&:ER OF LI UID WAST.E <br /> P� <br /> N pfIONE <br /> Prcx-I ADDRESS <br /> Number Street <br /> State Zip <br /> WAS SOURCE: DOMESTIC WASTEWATER ONLY from circle one): Septic Tank Portable Toilet <br /> PICK DAT$ l TI11� ) U 3 <br /> Q ANTiTgals <br /> I c t this waste wad delivered to the hauler named below far legal disposal at the site indicated <br /> Print me of Owner,occupant or AgeAt ignaiure of Owner,Occupant or Agent <br /> 2. i <br /> NA1viE Roto kooter <br /> BUS S ADDRESS <br /> Number street City State zip <br /> I certify t the described waste was hauled by me to the disposal facility gamed below. / <br /> PICC Station Permit No. Vehicle License No. b <br /> Printed am Hauler Sign�,,-aer <br /> i <br /> 3. I;,IV1rTG$ TION <br /> NAME ADDRESS: city ofMantcca WQCF 2450 West Yosemite <br /> Ave. Manteca CA 95337 <br /> I certify t the%tiler above delivered the desc lb d liquid waste to this d- o and that it <br /> accept jetted(circle one)material under the terms of the Receiving SudoP <br /> i <br /> Signature of Waste Facikty Operator <br /> DATE / / TIME]N '[U U TME OUT NSr QUANTTTY J Y r <br /> .Rcv,02/0 o assis�}/f� <br /> d 6�t6 'ON NNSI : OI 8[OZ 9 'qad <br />