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S9SZ 'ON W [l [ t [E `6 AN aW J paAIa�a� <br /> Crff OF NL <br /> 4,NTEC&F_QCF <br /> WASTE HAULER'S SOURCE CERTIFZCA-U N <br /> x• PRW-VCER OF LIQUID WASTE px .ZS <br /> Co PHONE <br /> PICK-UP ADDRESS Z /��1 r U� Z-.1Z Cq <br /> Number Street City state <br /> Zip <br /> WAS i SOURCE; DOMESTIC WASTEWATER ONLY from(cj,cle one): atEc Tak1v Portable Toilet <br /> PICK-TSP DATE 1D (� _TIME a 0 J y✓` QUAN'I'1T'Y els <br /> I c that this waste <br /> was delivered to the hauler named below for legal disposal at the site indicated. <br /> Printed Name of Owner,Occupant or Agent Si�fiatare of Owier,Occupant or Agent <br /> I <br /> 2. HAULER <br /> NAME Roto ter <br /> BUSINESS ADDRESS <br /> Number Street City State Zip <br /> I certify that the described waste was bauled by me to the disposal facility named below. <br /> Rxeivmg Station Permit No. Vehicle License No. <br /> �QIAV- � <br /> Printed Nanie of Hauler ture of er34H i <br /> a <br /> 3. G STAMLO <br /> NAMM AND ADDRESS: C5 f Manteca <br /> City oW QCF 2450 West Yosemite Ave. Manteca,.CA 95337 <br /> I certify that th�uler above delivered the descnbed liquid waste to ibis disposal facility,and that it was <br /> accepted%rejected(circle one)material under the terms of the Receiving Station Permit• <br /> 3' a of Was teac petrator <br /> DATE �!�''"l�O TIME IN. Tum ouT l I c NET QUANTITY ,yr G^ a1s <br /> Rev_02/09 o�ce as*tWvfftW <br /> Z 'd LSl6 'ON MH : l l LIN '6 'A ON I <br />