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r o tla a1ui aniaoa <br /> 856 ' N Wb'6l �Ol SIOZ 'l l ' S 1 P � ; <br /> CITY OF 1VYANTECA W Cl+' m <br /> . WASTE ILkL LER'S SOURCE CERTIFICATION <br /> i <br /> I. PRODUCER OF LIOI'W WASTE pg <br /> NAME i S S S . � - PNONEOf��S <br /> PICK-UF ADDRESS J Q ��.r�vj,y� iZ <br /> Number Street City State Zip � <br /> I <br /> WASTE SOURCE- DOMESTIC WASTEWATER ONLY from(circle one): ep c Tmk Portable Toilet <br /> PICK-UP DATE l �/S Tu+�irD I QUANTTI"Y gals <br /> I certify that this waste was delivered to the hauler natned below for legal disposal at the site indicated, <br /> vp Lp� I <br /> Printed Name of Owne ,Occupant o4,A,gent Si�iature of er,Occlant or Agent <br /> I <br /> 2. aAULER <br /> NAME Roto Rooter <br /> BUSINESS ADDRESS <br /> Number street City State zip <br /> I certify that the descn"l)%--ti waste was hauled by me to the disposal facility named below- <br /> Receiving l 7 i 361'5'.2 <br /> Receiving Station Permit No. _ �elzicle License No. <br /> T <br /> f � <br /> Printed Name of Hauler Signature of 114uler <br /> 3. RECF.fVIrTaG STATYOIv <br /> NAW AND ADDRESS= City of Manteca WQCF 2450 West Yosemite Ave,. Manteca,-CA 95337 j <br /> I <br /> I certify that the hauler above delivered the descmbed liquid waste to this disposal facility,and that it was <br /> actepted/rejected(cizcle one)material under the termas of the Receiving Station Paw t_ <br /> Signa e of Waste Vacflibperator <br /> DATE ` 1 l TIME INTIl1 OI7T NET QUANTTI y2 J s <br /> � r <br /> Rev.02109 oil awL-o r koyw <br /> i <br /> z 'd H66 "N NV�z : O[ S�Oz '< < 'daS <br />