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N1� 8811 '0N A d 6 0 ti 9102 'Zl 'das awil paniaaa� <br /> CITY OF ivLAN'TECA NVQCF <br /> WASTE RAULER'S SOURCE CERTIFICATION b <br /> I. PRODUCER OF LIQUID WASTE <br /> PHO: <br /> PICK-UP ADDIZPSS f��Q c� 1—Z1 1-1 <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): <br /> eptic Tank PortableToilet Other(describe) <br /> PICK-UP DATE TIME <br /> QUANTITY ,� als <br /> I certify that this waste was d livered to the hauler named below for gal disposal at site indicated. <br /> &hZt2 Ak �k-� <br /> A"(� ��Z <br /> Printed Name of Owner,Occupant Jr Agent a tore of Owner,Occupant or Agent <br /> 2. HAULER <br /> N.Aiv1E ROTO-ROOTER- Stockton <br /> BUSINESS ADDRESS 4223 Newton Road Stockton CA 95205 <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 License No L( <br /> Roosevelt Moore <br /> Printed came of[Tauler Signature dfHauler <br /> 3. RECEIVING STATION <br /> NAM]✓AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave., Manteca, CA 97337 <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility, and that it was <br /> aceepted/rej ected(circle one)material under the terms of the eceiving Station Permit. <br /> l <br /> Sig.uatu a of W'4ste Facility Operator <br /> DATE g TI'NfE IN '-55 L°l TI VE OUT NET QUANTITY 3 als <br /> Rev.02/09 Off=assistant/septic dclivcrics and data <br /> ti 'd 5965 '°N 910Z 'Zl 'daS <br />