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,May. 3. 2016 11 : 09AM No. 4985 . - P. 3 <br /> CITY OF MANTECA WQCF <br /> `,VASTE RAULER'S SOURCE CERTIFICATION 40 <br /> 1. PRODUCER.OF LIQUID WASTE PH • �J <br /> NAMEBal�'�" ( �C�PC Cc c��° , PHONE6 4 �' /� <br /> PICK-CTP ADDRESS J)j� 0 -S,. `�c <br /> Number Street City r State Zip <br /> WASTE SOURCE; DOMESTIC WASTEWATER ONLY from(circle one): <br /> eptic Tank Portable Toilet Other(describe) <br /> PICK-UP DATE �1,12eZTIME , QUANTITY 33 F, Vials <br /> I cert' that this waste was delivered to the hauler named below for legajdisposal at the site indicated_ <br /> Printed Name of Owuer, upant or Ab t Signature of Owner,O ant or nt <br /> 2. HAULER <br /> R <br /> NAME ROTO-ROOTER- Stockton <br /> BUSINESS ADDRESS 4228 Newton Road Stockton. CA 95205 <br /> Number Street City State Lip <br /> I certify that the described waste was ha <br /> uled/by me to the disposal facility named below. <br /> Receiving Station Permit No. °� _ ! Vehicle License - <br /> Roosevelt Moore <br /> Printed Name or Hauler x-signature of Hauler <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS: City of Manteca WQCIa 2450 West 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 Recei-wigStation ermit_ <br /> _7Z <br /> Signature of Waste Facility Operator <br /> DATE �/r' �! TIME 1N / 17��- <br /> TIME OUT r � NET(�UAN'I'I'fY <br /> Cicv,03/09 office assistantiseptic deliveries and data <br /> Received Time May. 3. 2016 11 : 05AM No- 0757 <br />