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S9WIN AVLO : h LIH 'S 'ady ;W11 pania3;� <br /> "'000. o�� <br /> CITY OF MANTECA-Wo ff <br /> ,j <br /> WASTE HAULER'S SOURCE CERTIFICATIQN <br /> l.. PRODUCER OF mom WASTE <br /> NAMES PHONE <br /> PICK-UP ADDRESS /gd30 ,�.�',���P% :� _ 'S33/�_ <br /> Number Street City^ State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): eptic T Portable Toilet <br /> PICK-UP DATE 3 2,3% � _ TIME� QUANTITY__Z,? gals <br /> I certify that this Waste was delivered to the hauler named below for legal sal at the site indlcatnd. <br /> Printed Name of Own r,Occipaut or Agent Si gi tnre of er,Occupant or Agent <br /> 2. HAULER � <br /> .I <br /> NAME Roto Rooter _ _ 1I <br /> ]3USINESS ADDRESS <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. Vehicle Ucense No.f% 6_ -2— <br /> Printed Name of Hauler SIOZ6tare of H&— <br /> a <br /> 3. BELVIYgiGSA ON <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,-CA 95337 <br /> I certify that thAauler above delivered the descnbed liquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material under the terms of the Receiving S erna� <br /> ature of e a erator <br /> �{1N <br /> DTTACE OUT \ r ' NET QUANT=22 2�ais <br /> ATT� � � IIvIE � / x� "� �`i <br /> Rcv,0210P office assiatEVfo= <br /> 'd 9L�L '°N Wyk l l l L l0Z S 'ady <br />