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��Lti 'oN WdSI �Z �101 'Ol '�a0 au�il�pa�n,ia�a� <br /> CITY OF MANTECA,WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1, PRODUCER OF LIOUrD WASTE pH <br /> __Z,�_- <br /> -T ) G' E <br /> NAME LA r d Ly,� u�-1%r e• ale�J eJOle P-- PHONE 9D .�'L--/ CQ i <br /> PICK-UP ADDRESS <br /> Number Street ,ty State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle Q P Tan Portable Toilet <br /> PICK-UP DATE .3 TIME (J� QUANTITY ,S D� gals <br /> I certify Haat this wase was delivered to the hauler named below for legal disposal at the site indicated. <br /> Printed Name of Owner,Occupant or Agent Signature o Owner,Occupant or Agent <br /> 2. HAULER s <br /> NAME Roto Rooter \ <br /> BUSINESS ADDRESS �'�.. </?'l 2�-o-z6- <br /> umber IV Street City State Zip <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No. Vehicle License No. <br /> Prin ed Name of Hauler Signature of Hauler <br /> 3. RECEIVING STATION <br /> i <br /> NAME AND ADDRESS: City of Manteca WQCP 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-the Receiving Station Permit_ <br /> �a_ta_re Waste Facility Operator <br /> DATE TIME IN 'Ojg TIME OUT NET QUANTITY l�_gals <br /> Rev.02/09 office assistant/forms <br /> ET/50 39dd �GiO J 0101 9Z6559b60Z 9T:VT ETOZ/OT/ZT <br />