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HSVON Wd8S : C 9 l 0 S! 'aplN aiu Jipanfa3a� <br /> CITY OF MANTECA WQCF <br /> WASTE MAULER'S SOURCE CERTIFICATION � <br /> 1. PRODUCER OF LIQUID WASTEH <br /> P <br /> NAME ;S 7 l' _ PHOM6 61 <br /> PICK-UPADDRESS S• �A g [� S <br /> Number Street City State Zip <br /> WASTE SOURCE- DOMESTIC WASTEWATER ONLY from(circle one): <br /> Septic Tan Portab a Toilet Other(describe) <br /> PICK-UF DATE ' TIME QUANTITY 33 L <br /> gals <br /> I certifv that this waste was deliv red to the hauler named below for legal disposal at the site indicated- <br /> Pouted Name oro er,Occupan r Agent Sign tore of Owner, •cupant o Agent <br /> 2. HAULER <br /> NAME ROTO-ROOTER - Stockton <br /> BUSINESS ADDRESS 4225 Newton Road Stockton_ CA 95205 <br /> Number Street City State "Lip <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No. / ,`__ _ VLof <br /> le Lice se No Z7:1 f `� <br /> 2 : _ <br /> Roosevelt Moore _ <br /> Printed Name of Hauler Signature Haule <br /> 3. RECEI'V'ING STATION <br /> MAIVIE 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 facility,and that it was <br /> accepted/rejected (circle one) material under the terms of the Re vin-Station Permit. <br /> X IL <br /> �1 <br /> Sign n Waste aci.lity Operator <br /> DATE TIME N -0 <br /> . . . TFiVIE LfT- . _ `ivT QUAN Tf l`Yr ga <br /> Pev.02/09 ofFcc assistant/septic deliveries and data <br /> S 'd �[ IN Wvlo :8 9M <br />