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f 1j 8850 '°N NHS :: 910 � 'Sl 'a �W au�il pania�a� <br /> CITY OF MANTECA WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF Ll()UID WASTE pH ' <br /> NAME L e. c�scgzde PHON-F_Caf) <br /> PICK-UP ADDRESS <br /> Number Street City State zip <br /> WASTE SOURCE: DOMES'T'IC WASTEWATER ONLY from(circle one): <br /> _5_e an Portable Toilet Other(describe) <br /> DATE TIME _ QUANTITY als <br /> I certify that this wastr:was delivered to the hauler named below for legal disposal at the site indicated. <br /> le.,k, (/V .-,C_?=, [r*<L, __TQ <br /> Fnnted i�lapne of Owvne ,Occupant or gen Signature of Owner,Oc u ant or ent <br /> 2. HAULER <br /> NAME ROTO-ROOTER- Stockton <br /> BUSINESS ADDRESS 4228 Newton Road Stocktorx CA 95205 <br /> Number Street City State zip <br /> I certify that the described waste was k'�jxuled by me to the disposal facility named below. ,r / <br /> Receiving Station PerraitNo. � 1 Vehicle License No / (�f6'�Z <br /> Roosevelt Moore <br /> Printed Name of Hauler Signature of Hauler <br /> 3. RECEDING STATION <br /> NAME.ANL)ADDRESS: City of Mianteca WQCF 2450 West Yosemite Ave., Manteca, CA 95337 <br /> I certify that the hauler above delivered the described liquid waste to this disposai facility,and that it was <br /> accepted/rejected(circle one)material under the terms of the eceivirw Station Pee it. <br /> Si,a,Aatu C 6t Ws3,a 1Fa ity Operator <br /> DATE F �J Til E IN TIME OUT , NET QUANT[TY�] als <br /> Rev.02/09 ofcC as3istanCseptic delivCxics and data <br /> a ti I ON MOO :R 9102 S l a �.N <br />