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a/a; it <br /> IM "N AdK :S 9102 Zl <br /> CITY OF MANTECA WQCF <br /> WASTE MAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LIQUID WASTE <br /> NAME PHO bo PICK-UPADDRESS <br /> Number Street City State Zip <br /> WASTE SOURCE: IC WASTEWATER ONLY from(circle one): <br /> ePtic Ta Portable Toilet Other(describe) <br /> DATE �l A' TIME QUANTITY �� �U als <br /> I certify that this waste}bras deliv d to the hauler named below for le disposal at the site ' dicat <br /> L—\rc�LAL& <br /> Printed Name of Owner,Occupant or Agent Sign ure of 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 /> Receivin;Station Permit No. Vehicle:-License No <br /> Roosevelt Moore <br /> Printed Name of Hauler Signature of Hadfir <br /> 3. RECEIVING STATION <br /> NAME AND ADDPESS= City of Manteca WQCF 2450 West Yosemite Ave., Manteca, CA 95337 <br /> 1 certify that the hauler above delivered the described liquid wasteto th' i sal fa ility,and that it was <br /> accepted/rejected(circle one)inaterial under the terms of the Receiv' g do P it" <br /> Signature o Wa a Facili Aerator <br /> DATE -/ TIME IN `Jf'�~ TIME OUT / - NET QUANTITY22 r�Ka1s <br /> Rev.02/09 office assisrant/septic deliveries and data <br /> S 'd H99 'ON Md : s 9102 11 '�aa <br />