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[StiVIN WdSI SIOZ Z 'ady auiil paniaaa� <br /> CM OF MAN"TECA WQCF <br /> WSI`E xA E S UXSo. URCE CE1tMICATI0N <br /> 1. PRODUCER OF LIQUID WASTE PH <br /> NAIv(E Ji—, _ PHONE <br /> PICK-UP ADDI2ESS-22&361 <br /> Number � <br /> Street city State zip <br /> WASTE SOURCE; DOMESTIC WASTEWATER ONLY iaom(circle on ptic T portable Toilet <br /> PICK-UP DAVE T24EE <br /> QUANTITY <br /> I certify that this waste was delivered to the hauler named below for lewd disposal at the site indicated_ <br /> r <br /> I <br /> Printed dame of Owner,Occupant or Agent Sign a of 0w1 r,°ccup or Agent <br /> Z. ULER <br /> NAME Roto Rooter <br /> BUSINESS ADDRESS r c ! ;y , ,;t g�-✓l cC `Jf-��1 p_ /� (J <br /> Number Street City State zip <br /> I certify that the descri-bed waste was,bauled by me to the disposal lhcility named below. <br /> Receiving Station Permit No, _ Z Vehicle License No.-2 <br /> ff I <br /> Printed Name of Hauler Signature of IIwer <br /> - RECEB-ING_UA'ITON <br /> NAME AND ADDRESS= Ci of Manteca <br /> �' W QCF 2450 West Yosemite Ave. Manteca,.CA 95337 � <br /> I certify that the hauler above delivered the described liquid waste to this disposal fiacility,and that it was <br /> accepted/rejected(circle one)material under the terms of the Receiving Station Permit. <br /> Signature of Waste Facility Operator <br /> DATE _ TIIklE IN �� 1v- T31VIE OUT <br /> NET QUANTITY l:57D, als <br /> ' I <br /> Rev.02/09 o$oc assistanyfoims <br /> ti 'd H6 'ON WdB [ :� S l OZ 'Z 'A dy <br />