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A -0/31 8911 'ON M60 :ti 9102 Zl 'daS 11111 paniaaa� <br /> CITY OF MANTECA WQCF <br /> WASTE HAULER'S SOXJRCE CERTIFICATION <br /> r r <br /> 1. PRODUCER OF LIQUID WASTE <br /> ?HONE���_ <br /> l r� <br /> PICK-UP ADDRESS��3n S rlG� fed [_, la1ir'a� C.� ���Fyo <br /> Number Street Citv State Zip <br /> WASTE SOURC DOMESTIC WASTEWATER ONLY from(circle one): <br /> Septic Tani: ' Portable Toilet Other(describe) c <br /> PICK-Ul'DATE �Z� �� TT1v1E QUANTITY_ <br /> I certify that this wasw was delivered to the hauler named beloPMLLY&A 0,0 A�4- disposal the site indicated. <br /> w f sal <br /> L� LZ,,d,-4,. <br /> Printed name of Owner, Occupant or Agent ignature of Owner,Occupant or Agent <br /> 2. RAULER <br /> NAME ROTO-ROOTER- Stockton <br /> BUSINESS ADDRESS 4228 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. / 2 l Vehicle License No�)��� <br /> Roosevelt tifoore <br /> Printed Name of Hauler Signature of Hauler <br /> 3. RECEIVLNG STATION <br /> NAME AND,ADDRESS: City of Manteca `VQCF 2450 Nest Yosemite Ave_, Manteca, CA 95337 <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility, and that it was <br /> accepted/rejected(circle one)material under the terms of the Ree iving Station P t. <br /> Si;n tore of Waste Facilityperator <br /> DATE �//5kJ�f0 TINM IN v�v TIME OUT NET QUANTITY 3S'61trazs <br /> Rev.02/09 officc assistant/sep[i�dcli'mics and data <br /> z 'd SS6S "N Wdll :t 9�0z 'Z � 'daS <br />