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S9SZ 'IN AHZI : II, LIR '6 AON anvil panI ;); <br /> CTI'Y OF MANTE9:A w CF �- I <br /> VYAS HAUL R'S SOURCE CERTIF TC TION <br /> .i <br /> 1. PRODCICER OF LIOUID WASTE PR <br /> PICT[-UP ADDRESS S-- fFN j.`�(/'1 PHONE,l � <br /> Q c L/Az� f� . Ccs rl <br /> Number Street City State <br /> zip <br /> WAS7 SOURCE: DOMBSTIC WA3TEWA,TER ONLY from(cite one): Septic Tankportable Toilet <br /> TIME Q �N IT]Y "Z <br /> 10 `that this waste was delivered to the h2uler named below fbr legal disposal at th site.indicated <br /> r � A <br /> Ijri:uted Name of Owner,Occupant or Agent <br /> Winfure of O mer,Occupant or Agent <br /> 2. A&U—MR <br /> NAME <br /> to ter i <br /> I <br /> BTJSMSS ADDRESS , <br /> Number Street City State <br /> zip <br /> I certify that the desm-bed wasta was hauled by me to the disposal facility named below <br /> Rec Station Permit No. Vehicle License <br /> 7� <br /> Printed Nam of Hauler I <br /> z Signature of er <br /> 3- REC GST TION <br /> NAME AND ADDRESS: City OfMaUreoa WQCF 2450 West Yosemite Ave. Mantma,,CA 95337 <br /> I certify' t theNauier above delivered the descrB>ed liquid wasroe to this disposal e <br /> 8ccepted/rejeeted(curie one)mat�edal udder the terms of the Receiving on Permit. '�d that it was <br /> i <br /> S' s e of Waste Facility Operator <br /> i <br /> DATE TUVIE INL <br /> XrnfE OUT ;`� NET QUANTITYY <br /> als <br /> Rev.02/09 o�eeass�M�(/fog ' <br /> I, 'd LSI6 'ON MZ I I L106 '6 'A ON <br />