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MVIN 'qaj awil paniaoad <br /> CITY OF MANTECA WQCF <br /> WASTE HAUTARIS SOURCE CERTIFICATION <br /> . 11 PRODUCER OF LY UID WASTE pH r <br /> NAME 1 S PHONE C /l <br /> PICK-UP ADDRESSZ _ '_ =a;; <br /> Number Stroet City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): <br /> Sept a Tank I PortableToilet Other(describe)_ j <br /> PICK-UP DATE TIME - QUANTITY � �aCaIs <br /> I certify that this waste was delivered to the hauler named below for at the site indicated- <br /> Printed-Name <br /> ndicated._Printed-Name of Owner,Occupant or Agent Signatre o Owner,Occupant or Agent <br /> 2_ HAULER <br /> NAME ROTO-ROOTER- Stockton <br /> BUSINESS ADDRESS 4228 Newton Road Stockton CA 95205 <br /> Number Street City State Zip <br /> I certify that the described waste was"hauled by me to the disposal facility named below_ <br /> Receiving Station hermit No. / '! Vehicle Licen. No_Zz:? LS <br /> Roosevelt Moore <br /> Printed Name of hauler Signature of Hauler <br /> 3. RECEIVTNCr 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 ane) material undLrthe terns of the y�aceiving�5tation Permit. <br /> Signature of`Vaste Facility perator <br /> DATE Q "� TRVIE IN r ?TIME OUT NET QUANTITY '2 gals <br /> Rcv.02/09 office assistant/sptic deliveries and data <br /> d 19�ti '�N WdU 910 6 dad <br />