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,Nov, 3. 2016 10 : 28AM No, 6390 P. 4 <br /> � � CITY OF MANTECA WQCF <br /> �lw V 3 20% WASTE HAULER'S SOURCE CERTIFICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIiTISEMAGES <br /> 1. rRODUCER OFLIQLFED WASTE pH (o <br /> NAME i C PHONE /Zd V 7�" — q// <br /> PICK-UP ADDRESS la'20TC5 Z41 roi>) <br /> Number Street City State zip <br /> WASTE SO E_RQjvIESTIC WASTEWATER ONLY from(circle one): <br /> Septic'i'ank Portable Toilet Other(describe)) <br /> PICK-UP DATE / TIME o - G QUANTITY �s als <br /> I e ify that this waste was vered to the hauler named below for egal disposal the site indicated. <br /> *Ak:1 <br /> P "ated Name of Owner,Occupant or A nt S4n re of Owner,Oeeupan gent <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 Permit No_ Vehicle License No O s <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., 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 one)material under the terms of the Receiving Station Permit. <br /> Signature of Waste Facility Operator <br /> DATE TIME IN �� � TIME OUT � NET QUANTITY ✓ / J /gals <br /> Rev.02/09 office mssiscant/sWic deliveries and data <br /> Received Time Nov, 3, 2016 10 : 23AM No- 0294 <br />