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0Q9/16/2014 09:36 2094655926 ROTO ROOTER PAGE 02/04 <br /> f CJ` <br /> 00(41 <br /> CITY OF MANTECA WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LIQUID WASTE ph <br /> ot ti P . PHONEl)�fS e <br /> S0 PHONE <br /> NAME: e, <br /> PICK-UP ADDRESS: �o`�Q Sb C�AI`1�.1'L L4041 1-0 f2 K-13<0 <br /> Number Street city...._ e Zip <br /> WASTE SOURCE. DOMESTIC WASTERWATER ONLY from (Circle One): eptic Tank Portable Toilet <br /> PICK-UP DATE: ��j TIME: O� -' � QUANTITY: :.2ef_2 GALLONS <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated. <br /> co <br /> Printed Name of owner,Occupant Or Agent Signature Of Owner,Occup n or Agent <br /> 2. HAULER <br /> NAME: � DI <br /> BUSINESS ADDRESS: b <br /> Number Street City State Zip <br /> I certify that the described waste was hauled by me to tie disposal facility named below. <br /> Receiving Station Permit No, T 010 ` Vehicle License No. <br /> Printed Name Of Hauler Signature Of Hauler <br /> 3, RECEMING STATION <br /> NAME AND ADDRESS: City Of Manteca WQCF 2450 W. Yosemite Avenue, Manteca, CA 95337 <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility,and that it was accepted/ <br /> rejected(circle one)material under the terms of the Receiving Station Permit <br /> Signature Waste Facility Operator <br /> DATE: 6A- - tq TIME IN: ��'.0' 1 TIME OUT: NETQUANTITY: '�'�3? GALS. <br /> r. <br /> Revised 10/17/12 <br /> Received Time Sep, 16, 2014 10: 33AM No. 7056 <br />