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EtiWI N M OE : I L �A au 11 paA1 3a� <br /> CTTY OF MANTECA W CF �- <br /> WASTE HAULFR°S SOURCE CERDIFICAnON J-3 2 C_2- <br /> l ODUCER OF UID BV TE _ <br /> PH <br /> NAME U'Pi1�� A G,P e PHONE �� <br /> PICK-UP ADDRESS 6 q/ i-I- , o <br /> Number Street City Stale Zig <br /> wASTF SOURCE: DOMESTIC WASMWATER ONLY fivm(circle one): Septic Tank Portable Toilet <br /> PICK-UP DATE G — �7 <br /> QUANTITYgals <br /> 2 I <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated <br /> Printed Name of Owner,Occupant or Agent <br /> Signature of Owner,OccuP=t or Agent <br /> 2. HAULER, <br /> NAN E Row Rooter <br /> BUSINESS ADDRESS x'22- <br /> .. Number Street City State Zip <br /> I cwufY that the described waste was puled by me to the disposal facility named below. <br /> Receiving Station Permit No.� Vehicle License No. <br /> I�.IC1 <br /> Printed Namae of Hauler <br /> Signature of Ranier' / <br /> 3• UCTIVING TION . <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave- Manteca,-CA 95337 <br /> I <br /> I cerdf3'that the Ruler above delivered the daubed liquid waste to this disposal facility,and that it was <br /> accepted/a ejected(circle one)material under the terms of the Receiving Station Permit_ <br /> Signature of waste Facility Operator <br /> DATE/ / TIIviE IN v ME OUT [ �� NET QUANTTfY��0 <br /> s <br /> Rev.02/09 office assisuir/runw <br /> Z 'd LLSL '°N WdLO l L lOZ � W <br />