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Nov, 3, 2016 10 : 28AM No, 6390 <br /> hell P, 21, <br /> GIME® CITY OF MANTECAWQCF <br /> NOV 0 3 20% WASTE HAULER'S SOURCE CERTIFICATION <br /> ENVIROWENTAL HEALTH <br /> PERM USEROCES <br /> 1. PRODUCER OF LIQUID WASTE PH - <br /> PHONE , <br /> PICK-UP ADDRESS � a �(�j C) a. �nYd� 9�-3 �c <br /> Number Street City State Zip <br /> WASTE SOURCE. DOMESTIC WASTEWATER ONLY from(circle one)_ <br /> Septic TanIC Portable Toilet Other(describe) <br /> PICK-UPDATE ^ ) ` — � TIME__;4:_�3 QUANTITY als <br /> I certify that this w was delivered to th auler named below for legal al e s to indicated. <br /> printed NaYe of dwuer,Occupant or Agent Signature of wner, ecupant 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.(:�—I�, I Vehicle Licens Nom ? � <br /> James Sanders f <br /> Printed Name of Hauler gnat au er <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 /> Signat r f Waste Facility Operator <br /> DATE J TIME rN. -30P ,TIME OUT NET QUANTITY l gals <br /> Rev.02/09 office assistant/septic deliveries and data <br /> Recelved Tirre Nov, 3, 2016 10 : 23AM No- 0294 <br />