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SIN "N Wd9l :l [ LIH 'S 'daS a'Wil paniaaaaj <br /> J <br /> Crr](QE MANTECA WOCF <br /> M <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF L101{.ITD WASTE pg <br /> NAME Oi \ PHONE <br /> PICK-UP ADDRESS <br /> Number Street City T State Zip <br /> WASTE SOURCE. DOMESTIC WASTI;'WATER ONLY from(circle one). Septic Tank Portable Toilet <br /> PICK-UP DATE"�, -� TIME d-, I, QUANITTY <br /> I certify that this delivered to the hauler named below for legal dibposal at the site indicated. <br /> Printed N of64uer, Occupant or Agent <br /> c o ent <br /> r - <br /> 2. HAULER <br /> NAME Rot.2 Roo= <br /> i <br /> BUSINESS ADDRESS <br /> Number Street city State zip <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No. I — \ Vehicle License No. <br /> Printed Name of Hauler tore of H9nler <br /> 3. MCE G STATION <br /> NAME AND ADDRESS: City ofMant=WQCF 2450 West Yosemite Ave. Manteca,-CA 95337 <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility, and that it was <br /> aecepted/rejeeted(circle one)material under the corms of the Receiving Sta� t <br /> S' e o Facffi perator <br /> DATEN t 2MQUANT <br /> Rev.02/09 ojM"assists fv= <br /> ti 'd 169VON WdLZ : ZI L [0Z 'S 'd;s <br />