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09/16/2014 09:36 2094655926 ROTO ROOTER PAGE 03/04 <br /> Z`4 <br /> �oa <br /> CITY OF MANTECA WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> ST <br /> 1. PRODUCER OE LIQUID WASTE ph <br /> NAME: 1R1'�1-S�SS '� PHONE:kfS, <br /> PICK-UP ADDRESS: RJ /A r w �4A <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTI WASTERWATER ONLY from (Circle One): eptic Tank,/_ Portable Toilet <br /> PICK-UP DATE: U TIME: L QUANTITY: '33d 121 GALLONS <br /> I certify that this waste was dlelivered to the hauler named below for legal disposal at the Site Indicated. <br /> . (- U Antl I C 6J l )eAAA.,' - <br /> Printed Name Of Owner,Occupant Or Agent Signature Of Owner,Occup nt r Agent <br /> 2. HAULER <br /> NAME: L� _ a <br /> BUSINESS ADDRESS: <br /> Number Stree[ city State Zip <br /> I certify that the described waste was hauled b sm��e to the disposal facility named below. <br /> Receiving Station Permit No. (X Vehicle License No, <br /> Printed Name Of Hauler Signature Of Hauler <br /> 3. RECEIVING 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 descrlbed 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 of waste Facility Operator <br /> DATE. I TIME IN: 1 40 f( iATIME OUT: 2 0 M NET QUANTITY: 33 J�;L GALS, <br /> J <br /> Revised 10/17/12 <br /> Received Time Sep, 16, 2014 10 : 33AM No. 7056 <br />