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tiH6 'ON WdZS :Z [ L10 O 1 panianaa ; <br /> CITY OF MANTECA wocF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> L PRODUQM OF LI UID w TE PH—A; <br /> NAME_ Gr C S Cil S C�i► Gil PHONE 7 <br /> PICK-UP ADDRESS �-4 J� �1 i� �1CGrn <br /> Number Street City State zip <br /> WASTE SOURCE: DOMESTICC WASTEWATER ONLY from((circle one). Septic Tank Portable Toilet <br /> PICK-UP DATE_ `_G —( TRvIE <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated_ <br /> Muted Name of Oar,Occupant or Agent Signature oktn trc'�Cnpant or Agent <br /> i <br /> 2. HAULER i <br /> NAME Doter <br /> i <br /> BUSINESS ADDRESS y� <br /> Number Street City State Zip <br /> I certify that the descn7)ed waste was hauled by]me to the disposal facility named below. <br /> Receiving Station Pernrit No. Vehicle License No� <br /> P4hted Name Ranter Signature,of Hao <br /> 3- G STATION <br /> NANffi AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,.CA 95337 <br /> I certify that the*hauler above delivered the descn liquid wasre to this disposal facility,and than it was <br /> accepted/rejected(circle one)material under the terms of the Receiving Station Permit. <br /> •i <br /> Signature of Waste Facility Operator � <br /> i <br /> i <br /> BATE J� L G� `T R M IN l Tr'M OUT OU NET QUANIZT y <br /> Rev.62J09 Office assisajWfU= <br /> 'I <br /> i <br /> ti 'd HN 'ON MOO : [ LI0Z 'Oil 'lnr <br />