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Nov. 3. 2016 10 : 28AM No, 6390 P. 3 <br /> RE C rV ED CITY OF MANTECA WQCF <br /> tnV 0 3 2016 WASTE HA,ULER'S SOURCE CERTIFICATION <br /> ENVIRO-WENTAL HEALTH <br /> PERMMSERVICES <br /> I. PRODUCER OF LIOUID WASTE pH <br /> NAME � [r � <br /> PICK-UP ADDRESS /el_lil <br /> Number Street City State Zip <br /> WASTE S DOMESTIC WASTEWATER ONLY from(circle one): <br /> =eptic Portable Toilet Other(describe) <br /> PICK-UP DATE D / TIME QUANTITY a(s <br /> I certify that this waste was delivered to the hauler named below for egal disposal a site indicated. <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 /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No. �.,L` hicle Li�seo <br /> i <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 /> 1 certify chat the hauler above delivered the described liquid waste to this disposal facility, and that it was <br /> accepted/rejected (circle one)inaterial under the terms ofthe Receiving Stations Permit. <br /> Signature of Waste Facility Operator <br /> DATE ` TIME IN � yl�' TIME OUT / � NETQUANTITY�9�Zals <br /> g <br /> Rev.02/09 office assis=t/septic deliveries and data <br /> Received Time Nov. 3, 2016 10 : 23AM No, 0294 <br />