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/YJ May. 1 2016 11 : 09AM No. 4985 \'P. 4 <br /> CITY OF MANTECA WQCF � <br /> WASTE HA[. LER'S SOURCE CERTIFICATION � <br /> 1. PRODUCER OF LIQUID WASTE pH <br /> NAME J ` Las r"" PHON <br /> PICK-UP ADIDR-ESS l'U: C) Le.MI`6 G'cc� JS_J,3z:7) <br /> Number Street City State Zip <br /> WASTES . + DOMESTIC WASTE WA f'Ek ONLY from(circIe one): <br /> eptic Tank) Portablq Toilet Other(describe) <br /> r� <br /> PICK-UP ATE �;�' ' TLME QUANTITY gals <br /> I certify that this waste was delivered o the hauler named below for 1 disposal at thq1t-indicatedd. <br /> Priv ed Name of Ownerccupant or . gent Signature of Owne , t or Agent <br /> 2. HAL LER <br /> NAME ROTO-ROOTER - Stockton <br /> BUSINESS ADDRESS 4228 Newton Road Stockton CA 95205 <br /> Number Street City State Zip <br /> I cortify that the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No_ Vehicle License No 7/ S ! " <br /> Roosevelt Moore L <br /> Printed Name of Hauler Signature of Hauler <br /> 3. RECEI WING STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave., Manteca, CA 95337 <br /> I certify that the hauler above delivered the described liquid waste to this disposal liacility,and that it was <br /> accepted/rejected(circle one)material under the terms of the ceivin Station Permit. <br /> sig t4 e 9f,/ante Facility Operator <br /> DAT"8 C a ../&_,.__TlML IN J''00J .UVIC OUT NET QUANTTTYS�2— Gals <br /> Rcv.02/09 ofrae ussistont/septic deliveries and data <br /> Received Time May. 1 2016 11 : 05AM No- 0757 <br />