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tiE61 '°N Wd Zl L1Z OZ 'Ind curd panic°a� ; <br /> CYT"'OF MANTECA 'WQCF ` <br /> �VA$"I'E MAULER'S SOURU CERTIFICATION <br /> X. ODU OF LI WASTE PH <br /> NAME c c�' A SC o PHONE �`d� 3 611-1y <br /> PICK-uP ADDltl:ss / a G 2!�nl�u <br /> Number Street City �t Zip <br /> I <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): <br /> Septic Tank Portable Toilet <br /> PICK-UP DATE -'' TIME / {arm QUA y <br /> I certify that was delivered to the hauler named below for legal disposal at j[h I e indicated <br /> C a-i*OL- rNG6U- <br /> Printed Name of ex,Occupant or Agent Signature of Odn ,Occupant or Age4t <br /> 'I <br /> 2. HAUS i <br /> NAME to Doter <br /> i <br /> BUSINESS ADDRESS <br /> Number Street City State Zip <br /> I certify that the desctsbed waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No' Vehicle License No--e2 6 <br /> Prated Name orf Hauler Signature <br /> 3. RECEIVING S TION <br /> NAME AND ADDRESS: City ofMant=WQCF 2450 West Yosemite Ave. Mmateca,.CA 95337 <br /> I certify that thAaDier above delivered the d liquid waste to thisosal <br /> acceptedfrei—ted(Circle one)material under the terms of the Receiving st tion p facility, d that it was j <br /> i <br /> Signature of W Fa Op or <br /> DATEL 6- � 1 TIME IN / U M E OUT (/o NEr QUA x3 MM <br /> Rev-OZ/O9 ofUceassis�atlfvuas _ <br /> ,I <br /> 0 'd OH '°N Wd00 : 1 LIE 'OZ '� nr <br />