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LM "N Md :S 91H 'Z [ ')aQ^ WIJ paniaO;� <br /> • r <br /> CITY OF MANTECA WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCEp.OF LIQUID WASTE pH <br /> NAME PHONE <br /> PICK-UP ADDRESS <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): <br /> eptie T Portable Toilet Other(describe) <br /> PICK-UP DATE._ QUANTITY5 nets <br /> I certify that this waste was delivered to tbe hauler named below for le 1 disposal at the sit dicated. <br /> alik <br /> Printed Name of Owner,Occupant or Agent Sign re of Owner,Occupant or Agent <br /> 2. HAULER <br /> NAME ROTO-ROOTER - Stockton <br /> BUSINESS ADDRESS 4228 Newton Road. Stockton C.A. 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 Permit No- / Ve Licen e No <br /> Roosevelt Moore _ <br /> Printed Name of Hauler Signai re of Hauler <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave-, Manteca, CA 95337 <br /> at the hauler above delivered the described liquid waste to is dis osal facility, and that it was <br /> a eepted ejected (circle one)inaterial under the terms of the RQceiv g St ion Permit. <br /> Signature of Was a Facility Operator <br /> DATE /- / c(/ TIME IN 1.3 Al TIME OUT 7 NET QUANTITY S�D gals <br /> Rev.02/09 office&ssisrant/scptic deliveries and data <br /> ti 'd ZZ99 'ON Md :S 91H <br />