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Oti68 'ON &00 : � S10Z 'Ol 'unr ;Wli paniaa;�! <br /> 1 1 i <br /> CITY OF N ANTECA W!QCF <br /> WASTE HAUZEFt'S SOURGE CBR"TIFICAUON j <br /> 1. PRO UCER OF LI UYD WASTE <br /> pH_Z,, cJ <br /> N.AME��`�•_SCa ( .Gt;�(�.� tit;�P PHOS `' l�� - ���(� <br /> 7 <br /> PICK,-UP ADDRESS l 26f ,,�c r 1 <br /> Number Street City State zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONT.X from(ci:roie one): ' tic Taak Portable Toilet <br /> �3 C' <br /> PICK-UPDATE <br /> / v QU <br /> TI1L �/] N'1TI Y 33e-�Z <br /> - <br /> I certify that this waste was delivered to the bauler mored below for IqW disposal at the site indicated_ <br /> � <br /> printed Ns�me of er, Pant ar eut P AgSig�stnre of Owner,Occupant or Agent <br /> 2. HAULER <br /> N,?.ME Roto Rooter . <br /> BUSINESS ADDUSS <br /> Number Street City State Zip <br /> I certify that the descn-bed Waste was hauled by me to the disposal facility nanaed below_ r <br /> Receiving Station permit No. ( Vehicle License No.'1,17W <br /> r r9` A 1 <br /> 1 d <br /> Printed Name of <br /> Hauler Signature of Hauler <br /> . t <br /> 3, ItECEIV�iG STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 Nest Yosemite Ave. Man <br /> tees,CA 95337 <br /> I <br /> I certify that the hauler above delivered the descri-bed Iiquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material under the terms of the Receiving Station Fermit <br /> S' a k—n'eFacility Operator <br /> DATE IN <br /> ��L;�- `TIME IN :5 01 TIMEOUT NET QUANTITY <br /> fF <br /> Rev.02/09 office Assisi foz m <br /> i <br />