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OAS "N AV10 :01 ti[H til 'ups ;aril pania)ad <br /> CITY OF MANTECA WOOF <br /> WASTE HAULER'S SOURCE CERTEFICATION <br /> 1. PRODUCER OF LIQUID WASTE pH <br /> NAME Entse, r �� PHO ` <br /> 1 <br /> PICK-UP ADDRESS_ � �3C� S< rw <br /> Number Street City State zip <br /> WASTE SOURCE: DOMES/IC WASTEWATER ONLY from(circle eptic Tank' rtable Toilet <br /> PICK-UP DATE / TIME QUANTITY als <br /> i <br /> I certify that this waste was delivered to the hauler named below for legal dispo at to in ' ate <br /> Printed Name of Owner,Occupant or Agent ignature of Owner,Occupant or Agent <br /> 2. HAULER <br /> NAME Roto Rooter <br /> BUSINESS ADDRESS dr'1 <br /> Number 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_ ^ f Vehicle License No., f;3 <br /> i <br /> Printed Name of Hauler Signature o auler <br /> 3. RECEIVING 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-the Receiving Station Permit. , <br /> i <br /> t <br /> Signatu f Waste Facility Operator <br /> DATE / TIME IN TIME OUT NET QUANTITY gals <br /> Rev.02/09 office assistant/forms <br /> 50/Z0 3Jt7d �13100il 0101 9Z6559b60Z S0:01 VT0Z/bT/T0 <br />