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HLti '°N WdSI :Z E[0Z '0 [ 'Oaa awil paniaOad <br /> CITY OF MANTECA W!2CF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF_LIQM WASTE pH f <br /> NAMB r l a� PHON&Da) 2 <br /> PICK-UP ADDRESS PKWV'A' <br /> Number Street City I State Zip <br /> WASTE SOURCE: AO STIC WASTEWATER ONLY from(circle one)_ ptic Tank portable Toilet <br /> PICK-UP DATE - TIME f I� . J1 QUANIITY -Z112 Gals <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated. <br /> Printed Name of Owner,Occupant or Agent Signature of Owner,Occupant or Agent <br /> 2. HAULER F <br /> NAA Roto Rooter F �+ <br /> BUSINESS ADDRESS `7 A �+it � 14-A <br /> Number Street City State Zip <br /> I certify that the de-scribed waste was hauled by me to the disposal facility named below. <br /> Rcceiviug Station Permit No. Vehicle License No. <br /> Printed Name of Hauler Signature of Hauler <br /> 3. RECEVING STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 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/rejected(circle one)material under the terms of,&e Receiving Station Permit. <br /> Signature of Waste Facility Operator <br /> DATE TIME IN �� .�lv TIME OUT NET QUANTITY 3 a0Q gals <br /> Rcv,02/0 office assi=ntlforms <br /> CT/L0 3!DVd d=M i 01021 9Z6S59b60Z 9T:t T OTOZ/OT/ZT <br />