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ll6Z '°N NOSI 9 0Z '9l 'upr aWIj paAI ;3 ;y <br /> CTI'Y OF MAMCA WCF <br /> �r I0*7 <br /> WASTE RATTLER'S SOURCE CERTIFICATION <br /> L EROA10CER OF LLO - <br /> WASTE <br /> Il; <br /> I Q <br /> NAME! lc7 d Y �CL S C. Q PHONE vZ��9 S��✓� y �I <br /> PICK- ADDRESS /a O 0 <br /> i' Number Street City State Zip <br /> WAS SOURCE: DOMESTIC WASTEWATER ONLYfrom(circle one): Septic Tank Portable Toilet <br /> PICK- Ethis <br /> 5 / / =,M 7 �.C7 QUANTITY 8 c� <br /> I c wastewas delivered to the hauler named below for legal disposal the site indicated. <br /> Printed erne of er,Occupant or ent S' tare ot OwnVm.acclulmdt,or Age* <br /> 2. UT.RR I <br /> NAME <br /> I! Roto Rooter <br /> x;uszm ,,s ADDREss <br /> Number Street City State Zip <br /> I cetifyli at the described waste wHs� / <br /> hauled by me to the disposal facility named below. <br /> Rccei Station Permit No. `7 0a — I Vehicle License No. <br /> lei ;i <br /> Punted a of Hauler Signa of$galer <br /> 2 . <br /> 3. &EggMG STATION <br /> I 'I <br /> NAME ADDRESS: City ofMauteca WQCF 2450 West Yosemite Ave. Manteca,-CA 95337 <br /> 'q <br /> I ceitify It theeauler above delivered tate descn-bed liquid waste to this disposal facility,and that it was <br /> accept . ejected(circle one)material under the terms of the Receiving Station permit <br /> S' of W ste acility Operator <br /> DATE S�- TRUE IN I ',.���M TBm OUT NETUANTTTY i <br /> Q <br /> r. <br /> Rev.02/09 o assist fbnw <br /> ill <br /> Z 'd 0096 '°N Wd65 1 9 1 H '9l 'upr <br />