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J ( Nov 3 2016 10: 29AM No. 6390 P. 5 <br /> CITY OF MANTECA WQCF <br /> E I'V 6 3 2016 <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMUSERVICES <br /> I. PRODUCER OF LIQUID WASTE (p <br /> /,,�1� P <br /> NAME k 0 r l..L�S ' A �� PHONE�a�D <br /> PICK-UP ADDRESS Z A <br /> Number Street City State Zip <br /> WASTE S MESTIC WASTEWATER ONLY from(circle one)_ <br /> Septic Tan Portable Toilet Other(describe) <br /> PICK-UP DATE elD / TIME '15 <br /> QUANTITY iv als <br /> 1 certify that this waste was Nivered to the hauler named belowal disposal 'a site inMated. <br /> t <br /> _P <br /> ��I Lr1ZyL_('�_�� <br /> Printed Name of Owner,Occupant or Agent Signature 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 /> 1 certify that the described waste was <br /> hauled by me to the disposal facility named below. <br /> Receiving Station Permit No. / Vehi5le Licee <br /> 1 <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., Mantec A 95337 <br /> I c®rtify that the hauler above delivered the described liquid waste to this dis al f ity, an it was <br /> accepted/rejected (circle one) 'material under the terms of the Receiving tion P it_ <br /> Signature bf Waste Facility Operator <br /> DATE 1`C TIME IN � I J <br /> TME OUT NET QUANTITY gals <br /> Rev.02/09 office assistant/septic deliveries and data <br /> Received Time Nov, 1 2016 10 : 23AM No- 0294 <br />