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8900N WdH :: 9Z S 'uny auil paniana� <br /> CITY OF MANTECA WQC <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. MQDUCER QELIQUM WASTE pH <br /> _L, <br /> NANE8 e_ PHONE <br /> PICK UP ADDRESS <br /> Number Strret City $tate <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY 4om(circle orae): Septic Tank Portable Toikt <br /> PICK-UP DATE TD. �� � QUAN3TTY <br /> I certify tbat tba writs wrs delivered to the b=ier nsmed below for hW1 disposal at the site todicattd � <br /> Printed Name of Owner,OwgnW or Agent J of Owner,'Oet4mai or Agent <br /> 2. HAULM <br /> NAME Rota Rooter <br /> 11`�"�. <br /> N street City s=ane zip <br /> I certify that the described waste was hauled by me to the disposal facility ttameti below. <br /> Receiving Ston Permit Vebicle Liceme No. <br /> Printed Name of H=1& V tie of H:{ <br /> 3. <br /> NANS AND ADDRESS: City of Manteca WQCF 2450 Nest Yosemite Ave. Maw-CA 95337 <br /> I ca-tify that the isavlor above delivered the dc=-bed liquid wase to this disposal facility,and that it was <br /> accepted/rejected(circle one)material undrr the tams of the Receiving Station Permit. <br /> Sigaatm of Waste Facility Operator <br /> DATE `S /�i� M E IN '; =OUT /�' �5 N T QUANZITI, <br /> Rev.M109 or= eliv <br /> Z 'd ELS 'ON Wdso : Z 91H 'S '_nv <br />