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8210 '°N 09� : 11 9lH '0l 'J)0 aril paAl ;�;� <br /> M ` 013� <br /> CITY OF MANTECA. WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> I. PRODUCER OF LIQUID WASTE pH 'r, <br /> PICK-UP ADDRESS <br /> Number /Street City State Zip <br /> WASTE OMESTIC WASTEWATER ONLY from(circle one): <br /> Septic Ta�. _777TINM <br /> Other(describe) <br /> PI -UP DATE_ <br /> r� ___--QUANTITY 2h�(_�+ gals <br /> 1 certify that this waste Was delivermd to the hauler named below for legal disposal at the site indicated. <br /> 01 <br /> Printed Name of Owner,Occupant or Agent ignature 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. r <br /> Receiving Station Permit No__ - Vehicle Li se No <br /> _Roosevelt Moore 7 <br /> Printed Name of hauler Signature of auler <br /> 3. Rl✓CErVING STATION <br /> NAMI;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)inaterial under the terms oftation Permit. <br /> Sig re of Waste Facility Operator <br /> DATE � TIME IN Z-S-D M TIME O UT >.�f_6 NET QUANTITY > C) <br /> gals <br /> Rev.02/09 office assivnnt/scptic dclivcrics and data <br /> 9 d 1619 'ON Wdl� : l l 9102 '01 '130 <br />