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ZI 'IN AV�S :8 MI '6l 'ung aWl j pania)9�1 <br /> i <br /> 40 <br /> CITY OF MANTECA MLQCF <br /> WASTE ISA 'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LIQUID WASTE pg <br /> NAME PHONE v f <br /> Plc -UP ADDRESs Col <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circIe one): Septic Tank portable Toilet <br /> PICK-UP DATE © l Z-! 7 TIME 2 �'/CC) CIUANIITY srals <br /> I certify that this w=e elivered to the hauler named below for legal at the site indicated, <br /> Printed Name of Owner, ccapant r Agent Sigxtature of Owner,Occupant or Agent <br /> 2. HAULER i <br /> I <br /> NAME Roto Rpoter <br /> BUSINESS ADDRESS 2-2- '0�n o Gi�ci k1 Ccs (iS?-C5-- <br /> Number Street City State Zip <br /> I certify that the described waste was hauled by me to the disposal fac�7ity named below. <br /> Receiving Statiou Permit No. �Z - / Vehicle License Noll <br /> Pri uteri Nam�of Hauler Signature of Hg <br /> 2 a <br /> 3. G STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,•CA 95337 <br /> i <br /> I Certify that the%auler 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 Receiv]qzpaxature <br /> Station P <br /> i <br /> of Waste Facility Operator <br /> i <br /> { <br /> DATECS- <br /> `I/liMg 1N OUT Lc r NET QIJANTITY 2aLs <br /> Rcv.02/09 office sss�fox= . <br /> 'd ll6L 'IN Wd00 : 6 t [H '61 'un0 <br />