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SIZZ '�N Wd8l Zl LI0 5 'daQ awil paniaaa� <br /> CUY OF MANTE l <br /> ca wocF <br /> WASTE HAULER'S SO CE CERTIFICATION <br /> A. pRODUCFR QJF LIQUID WASTE pg <br /> NAME O\ Q �G PHONE <br /> PICK-UP ADDRESS b <br /> q o •i <br /> Number Street City State Zip <br /> WASTE SOURCE. DON�STTC WASTEWATBI,ONLY from(circle one): Septic Tank Portable Toilet <br /> PICK-UP DATE" j� TIME ` G' QUANITI Y <br /> I certify that this waste taa,delivered to the hauler named below for legal disposal at the indicated. .I <br /> Printed 30"ie4Owner, Occupant or Agent S�grta o ,Occupant or Agent <br /> i <br /> 2. .HAULER I <br /> NAME R�t=DRESS <br /> susllvESs <br /> Number street C► state zip <br /> I certify tbat the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No._,� - Vehicle License No. <br /> Printed Name of Hauler $ lure of <br /> 3. RECUVING STATION I . <br /> NAME AND ADDRESS: City of Manteca V'IQC F 2450 West Yosemite Ave. Manteca..CA 95337 <br /> I certify that the%auler above delivered the descdbtd liquid waste to this disposal fac' ' <br /> an tit <br /> accepted/rejected(circle one)material under the terms of the Receiving Station P <br /> • i <br /> i <br /> Signature of Waste Facility Operator <br /> DATEI A1 i J <br /> TIIviE IN TIME OUT NET QUANTITY _ L-als <br /> Rcv.02/09 office assistaat/fv= <br /> Z d <br /> d <br /> 16H "N Wd9l : Z [ LIN 5 ad <br />