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IZSL '°N ABLE tiIOZ l l 'A0N �IWIJ `pani�a�a <br /> i <br /> CITY OF MAN"FECA W CF DCS <br /> �� <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> I. MDUCER QLJ IOUID WASTE PH <br /> NAME �. �� �•r �� <br /> PHONE­ � <br /> PzCK-UP ADDRESS t b b S-. yJ_ - �- <br /> rf � C� <br /> Number Street City state Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER.ONLY from(circle on�r ep#xc Tank Portable Toilet <br /> PICK-UP DATE__.l 0 ,TZM QUANTITY <br /> I certify that this waste was delivered to the hauler n=,ed below for legal disposal at the site indicated_ <br /> Printed Namewn ,Oceut �Or�g�ent � Signature,of dwneir,O enpani r Ageut <br /> 2. HAULER <br /> NAME Roto Rooter <br /> BUSINESS ADDRESSpaC� <br /> Number street City State Zip` <br /> T certify that the descambcd waste was hauled(by me to the disposal faciUty named below. <br /> Receiving Station Permit No. ! Vehicle,License No-2 <br /> Prim#ed Name of Uaaler Signature of Hwer <br /> ,f <br /> 3. RECEIVING STA ON <br /> NAME ANL}ADDRESS: City of Manteca WQCT 2450 West Yosemite Ave. Manteca,•CA 95337 <br /> i <br /> I certify that the hauler above delivered the described ligdd waste to this disposal facility,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 /> GATE -x -1 TIME IN - '. ` TIME OUT NET QUANTITY L gals <br /> ;i <br /> I <br /> I <br /> Rev.02/09 ofnce assisTant/fa= <br /> S 'd l [H "N Wdtiti tiIOZ l l 'A ON <br />