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H °ON M06 :: SIOZ0 °nrj aw pan i a3a� <br /> CITY OF MANTECA'WQCF Oslo � <br /> WASTE HAULMS SOURCE CERTIFICAMN <br /> 1. PRODUCER OFLIQUID WASTE pU <br /> NAMir y PIIONfl yd`S /l�/ <br /> FICK-UP ADDRESS [ICS <br /> Number Street City State zip <br /> WASTE SOURCE: DOMESTIC>WASTEWATER ONL,tY from(circle one): eptie-Tank portable Toilet <br /> PICK-UP DATE 6 .//�I /J <br /> -- QuArrar= 336F-g gals <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated, <br /> SAT-`e <br /> printed Name of Owner,Oc u ant or p Agent Signature of Owner, upant tAgent <br /> 2. HAULED <br /> NAME Roto Roo-ter <br /> BUMESS ADDRESS r ei�; 1 vt <br /> Number Street City State zip <br /> I certify that the descabed waste was bauled by me to the disposal facility named bellow. <br /> Receiving Station Permit No. � r Vehicles j <br /> License No. <br /> Printed Name of Hauler Signature of 04uler° <br /> 3. RECEIVMTG STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,,CA 95337 <br /> i <br /> E <br /> I eerffy that the hauler 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,P <br /> ignatare of waste Facility Operator <br /> DATE '� TIME IN T - 3 '7 TINE OUT r C'ONET QUANT'IT'Y �'� <br /> I <br /> i <br /> i <br /> Rev.02/09 office ssSistMWfo= <br /> 'I <br /> ti d �lC� 'IN Wd�Z Z S�oz Z lnf <br />