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MFIN Ndll : S 9l0Z � l 'lnr awil"pani� d <br /> CITY OF A-kNTECA WQCF 7 <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LIQUID WASTE pH <br /> NAME PHOT <br /> PICK-UP ADDRESS 0203b <br /> Number Streat City State c Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): <br /> tic Tank Portable T flet Other(describe) <br /> PICK- TIME I(�C/ -- QUANTITY gals <br /> I certify that this waste was <br /> k)Aj <br /> s delivered to the hauler named below for legal disposal a tha site indicated. <br /> pfna, " <br /> Printed Name of Owner,Occupant or Agent Sin ure of Owner,Occupant or Agent <br /> 2. HAULER <br /> NAri,f F_ ROTO-ROOTER- Stockton <br /> BUSINESS ADDRESS 4225 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 /> lZeeoiving Station Permit No., �� / Vehicle License No <br /> Roosevelt Moore <br /> Printed Name of Hauler Signature of Hauler <br /> 3. R.ECEI-VLNG STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave-, Manteca, CA 9-5337 <br /> 1 certify that the hauler above delivered the described liquid waste to this disposal facility,and that it was <br /> accepted/rejected(cizcle one)material under the terms tatiou Permit. <br /> E;_ig4�atu=reolf l aste Facility Operator <br /> - — -��- FI1`� --=FSM Q --- TAIv�FTYG - <br /> Rev.02/09 office assistant/scptic deliveries and data <br /> � 'd ESS "N WdEl :S 9102 lnr <br />