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tiEtiZ 'ON PH : 6 LIE 'W110 auiil pania3a <br /> CITY OF MANS-ECA CF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LIQUID WASTE pg _ <br /> NAME a�S _ (f S C- 7 E PHONE 1 s y//L <br /> PICK-UPADDRESS CC �s 6 <br /> Number Street City State zip <br /> I <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): Septic Tank Portable Toilet <br /> PICk-UP DATE_a2M 00 l Tn4F_ QUANTITY eels <br /> I certify that this waste was delivered to the hauler named below for legaldisg�sal at the si indicated. <br /> J1 <br /> Printed flame of Owner, upant or Agent5ggathre of Owner,Occupant or Agent <br /> i <br /> 2. HAULS <br /> NAME R t i <br /> � / �� .i <br /> BUSINESS ADDRESS �j'2� nF3lI l ��-- S <br /> Number Street City State Zip <br /> I certify that the described waste washauled by me to the disposal facility named below. <br /> p <br /> Receiving Station Permit No. `2,— Vehicle License No__2 Z– <br /> Printed NIALe of Hauler Signature o uler <br /> e <br /> 3- RECYJVING SIAMIS <br /> NAME AND ADDRESS- City Oflv311teca WQCF 2450 West Yosemite Ave. Manteca,•CA 95337 <br /> � i <br /> I certify that the*bauler 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 Receiving Station Permit <br /> X-gvahwe of Waste Facility Operator <br /> I <br /> DATE OTIME /TIv TIlAE OUT NET QUANTITY gals <br /> I <br /> Rcv.02/09offocasAstmVf m ' <br /> 'I <br /> 'd IL69 "N AVZ� 6 L 'll PO <br />