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[ HS0 'ON AM :L 9�0� 'Sl,'JpW�'-9w;I P;AIa0a� <br /> • I! .-� I <br /> CITY OF MANT.ECA WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION � <br /> 1. PRODUCER OF LIOUED WASTE pI-; <br /> NAME Oci&4 <br /> PICK-UP ADDRESS <br /> Number Street City State Zip <br /> WASTI Q SRC' O�IESTiC WASTEWATER ONLY from (circle one): <br /> Septic Tank P rtablle Toilet Other(describe) <br /> PICK-UP DATE_ / TIME •sL1rlNTITY <br /> Rals <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the sit - dicated. <br /> Printed Name of 04ner,Occupant :fig nt Signature of Orwne , ccupant Agent <br /> 2. 14AULER <br /> NAME ROTO-ROOTER- Stockton <br /> BUSINESS ADDRESS— 4228 Newton Road Stockton CA 95205 <br /> Number Street City State -dip <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No. Vehicle License Nd / <br /> Roosevelt Moore <br /> Printed Name of Hauler Signature of Hauler <br /> 3. RECEIVING 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 facility,and that it was <br /> accepted/rejected (circle one)material under the terms of the Deceiving Station Permit. <br /> Sigdale+ Waste acil�ty Operator <br /> DATE 1 TIME INTIME OU'f NET QUANTIT-�33 <br /> Vials <br /> Rev.02109 6ff-4n assistint/septic deliveries and dura <br /> 'd �[9� '�� <br />