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MEIN AdO6 :S 9106 2 'unr .awil paAI ;0;d <br /> CITY OF MANTECA WQCE <br /> WASTE HAULER'S SOURCE CERTIFICATION .r <br /> l.. PRODUCER OF LI T�I.D WASTE <br /> PHON <br /> PICK-UP ADDRESSf.:L �f��i'. <br /> Number Street City State Zip - <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from (circle one). <br /> eptic' c Tank Portable Toilet Otber(dzscribe) <br /> PICK-UP DATE_ / r'r TIIVfE �! .� UANTI'TY �5 - <br /> Q <br /> J certify t #this waste was delivered to the hauler named below for legal disposal at the site indicated. <br /> Printed Name of Owner,Oc4pant or Agelnt Signature o Owner,04ceupa or Agent <br /> 2• HAULER <br /> NAME ROTO—ROOTER- Stockton <br /> BUSINESS ADDRESS 4228 Ne"-ton Road Stockton CA 95205 <br /> Number Street City State Zip <br /> 1 certify that the described waste was hauled by me to the disposal facility named below_ <br /> 9 �/ <br /> Receiving Station Permit No. Vehicle License N <br /> 9za/6)i.��71 <br /> Raosevelt Moore . _ <br /> C.� <br /> Printed Name of Hauler Signature of Hauler <br /> 3. RECEI'VINC STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave., Manteca, CA 95337 I <br /> i <br /> I certify that the hauler above delivered the described liquid waste to this sal cility, and that it was <br /> accepted/rejected(circle one)material under the terms of the fieceivi g S ion ertnit. <br /> r <br /> Signature of tiYaste eacility U rator <br /> i <br /> DATE _TIME _ IYI TIME OUT �� (/ dy NFT QUANTITY ,7C1 -als <br /> F.-.02/69 office a ssistantlscptic delivmics and data <br /> i <br /> 'd 2965 'IN WdE6 :� 9106 2 '�n r <br />