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OCH "N M00 :� SI0Z '0l -unr awil paniana� <br /> CITY OF MANTECA W CF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> Z. PRODUCER OF LIQUID M ABTE PH • d <br /> NA2vM G� <br /> .,.._ PHOS�.� !� <br /> PICKAW ADDRES$ <br /> Number Street City tate Zip <br /> I <br /> WASTE SOURCE: DOMEST C WASTEWATER ON`L fY from(circle one): eptic T Portable Toilet <br /> PICK-UP DATE / I'1]1� // _ QUANTIIY 33SS <br /> I certify that this waste was delivered to the hauler named below for Ieg disposal at the site indicated.j <br /> Printed NabuF of er,Qce " ant or A�.-ent S400tnre of Owner,Occupant or Agent <br /> 2. HAILT.Fi2 <br /> NAME Roto Rooter <br /> BUSINESS ADDRESS �.�-r i F�`�. �i� � � �'��s 6 <br /> Number Street City State Zip <br /> I Cwtify that the described waste was hauled by me to the disposal facility gamed below. <br /> Receiving Station Permit No. rig f Vehicle Lieense No.22 , .�, i,�. <br /> Panted Name of Hauler Suture of H4uler <br /> I <br /> 3. RJECEM <br /> INGSTATION j <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,.CA 95337 i <br /> I certify that the hauler above delivered the described liquid waste to Ibis disposal facility,and that it was <br /> scceptedlrejected(circle(ne)material under the tezms of the Receiving Station Pm►ait. <br /> Signature of Waste Facility Operator <br /> DATE 0 ti TIME IN t t`.3 TD4F,OUT S6:1;:� NET QUANTITY ' gals <br /> Rev.02/09 ofticc 3ssistani/fo= iI <br /> d SLtiZ �N Wdso :Z M6 'wunr <br />