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16�—.Lc 0IOS '�N 010 :01 tiH6 til �u�p_auil pan i a)a� <br /> CITY OF MANTECA WOCF <br /> WASTE HAULER'S SOURCE CERTISCATION <br /> 1. PRODUCER OF LI UID WASTE pH <br /> C 0�.) c� J <br /> NAME .� j SL. S c��� PHONE <br /> PICK-UP ADDRESS / Q 'Z� S' • 611'�Gt v4 z":Lw1f 0p <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTF WASTEWATER ONLY:from(circle one) eptic Tank Portable Toilet <br /> PICK,-UP DATE /�Z �/�3 - TIME I D '�C� QUANTITY z� als <br /> I certify that this waste was delivered to the hauler named below for legal dispopatsite ' ated_Printed Name of Owner,Oeenpant or Agent Sfgnaupant or Agent <br /> 2. HAULER <br /> NAA Roto Rooter ++ �� ,_ <br /> BUSINESS ADDRESS ' 2[t)�6vL SLCC�t�`'t <br /> Number Street City State Zip <br /> I cer*that the described waste was hauled by me to the disposal facility named below. <br /> 12eceiving Station Permit No. �Q` ' / Vehicle License'No. <br /> Printed Name of Hauler Signature o auler <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS: City of Manteca'WQCF 2850 West Yosemite Ave. Manteca,CA 95337 <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility,and that it was <br /> accepted/roected(circle one)material under the terms of-the Receiving Station Permit <br /> Si-g a a!of Waste Facility Operator <br /> DATE �0 �3 TIME 1N TIME OUT NET QUANTITY gals <br /> Rev.02/01' fffice assistam5 ms <br /> 50/b0 �GiOO�J 010 1 K6999b60Z 60:0T 7T0Z/bT/T0 <br />