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01/14/2014 10:03 2094655926 ROTO ROOTER PAGE 05/05 <br /> .gyp T <br /> 3�q z <br /> CITY OF MANTECA•W CF <br /> WASTE H,A..ULER'S SOURCE CERT ICATION <br /> 1. PRODUCER OF LJQI WASTE g <br /> P <br /> PHO � <br /> PICK-UPADDRESS d _ Aro ZD <br /> Number Street City State zip <br /> WASTE SOURCE: DOMESTI WASTEWATER ONLY from(circle one):�SepticTan Portable Toilet <br /> PICK-UP DATE QUANTITY 06 <br /> gals <br /> I certify that this waste was delivered to the hauler named below for legal disposal at to in ed, <br /> Printed Name of Owner,Occupant or Agent Signature of Owner,Occupant or Agent <br /> 2. SAiTLER <br /> NAME o�RootBUSINESS AD <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. <br /> r Vehicle License No. <br /> Printed Name of Hauler Signature of Haule <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 terrns of-the Receiving Station Permit. <br /> Sigmatur Waste Facility perator <br /> DATETIME 1N / 4,� TIME OUT NET Q•UANT1T als <br /> Rev.02/09 office assistant/forms <br /> Received Time Jan, 14, 2014 10: 01AM No, 5010 <br />