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5911 "N AVLO : h LIH 'S 'AdV auail paniaaaa <br /> :I <br /> CITY OF MAMCA.w CF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LIQUID WASTE pH . c� <br /> PUONE <br /> PICK—UP ADDRESS /.Q 7 <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): <br /> S epti T Portable To�1et <br /> PICK-UP DATE "/ THVIE �' QU seals <br /> I certify that this waste was delivered to the bauler named below for legal dissposal at the site indicated. <br /> Printed Name of Owner,Occupsmiror Agent Sjgpsture of Owner,Occupant or Agent . <br /> 2. AAULER i <br /> I <br /> NAME Roto Rooter <br /> BUSINESS ADDRESS 14/-, <br /> Number Street - city State Zip <br /> I certify that the described waste was hauled by me to the disposal fueffity named.below. <br /> Receiving Station Permit No. q'w ' Vehicle Licensee No. <br /> Printed Name of Hauler ? rgnature of HsIer <br /> 3. RF,OEIy>IV STATION - <br /> �_ <br /> NAME AND:ADDRESS. City of Mauteca W QCF 2450 West Yosemite Ave. Manteca,-CA 95337 <br /> I certify that the hauler above delivered the descn�bed liquid waste to this disposal facility,and that it was <br /> accepteNrejected(circle one)material under the terms of the Receiving Station Permit. <br /> 1 <br /> S e of este Facility Operator <br /> DATE , I1 TTI��TN (O� 5• TIME OUT _ , , NET QUANTITY "Z gals <br /> i <br /> \ Rev.02109 offica asA=MVf0mas <br /> Z •d 9L�L 'aN — AVS l : l l L l H •S 'a dy <br />