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tiHPIN &H : 6 RlH '6 'ady ';wi j pania�;� <br /> CITY OF MA.N?'ECA W C)F <br /> WASTE HA.ULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LIQUID WASTE pl, <br /> NAME 1,0 r-e D e-V&[o,0rhe., ' PHONE a D o 7, k� S <br /> PICK-UP ADDRESS � � /_ <br /> Number Street City State Zip ry <br /> WASTE SOMCE; DOMESTIC WASTEWATER ONLY from(circle one): Septic Tank Portable Toilet <br /> PICK-UP DATE L TRIM—_0.I 1 QUANTITY gals <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indieat'cd. <br /> Printed Name of Owner,Occupant or Agent Sign Lure of Owner,Occupant or Agent <br /> 2- HAULER <br /> NAME Roto Rooter <br /> BUSINESS ADDRESS �� J <br /> umber 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. T Vehicle License No. <br /> Printed Name of Aauler 9& e o ul'er <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 facjiity, and that it was <br /> accepted rejected(circle one)material under the terms of the Receiving Station Permit. <br /> Si' ait&e of Waste FacWty Operator <br /> ACO <br /> DATE �( TMMIN3'_�7> PM -fnVfE OUT "I NET QUANTITY U gals <br /> C) <br /> Rev.02/09 office assistanr/focros <br /> 9 'd 6266 'ON AVS l 6 2l0 '6 a d <br />