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HIFON 09� : [ [ 9lH '0[ '130 ;Wli paniaD;� <br /> CITY OF MANTECA WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> I. PRODUCER OF L,IOUED WASTE pH <br /> NAME_ <br /> PICK-UPADDRESS__ZP2� Q <br /> Number Street City State Zip <br /> WASTE$O OMESTIC WASTEWATER ONLY from(circle one): <br /> eptic Tank Portable Toilet Other(describe) <br /> PICK-UP DAVE_. �/ `� TIME QUANTITY teals <br /> I cSTtitfy that this waste was delivered to the hauler named below fI Aff V_&K o legal disposal at a site in ed. <br /> �Ik� <br /> Printed Name of Owner,Occupant 4 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. -/ Vehicle license No� C/ <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 40faste <br /> ' ion Permit. <br /> 1 <br /> Signa u Facility Operator <br /> DATE /' / /� TIME IN J, TIME OUT 3'��NET QUANTITY �als <br /> Rev,02/09 office assistant/septic deliveries and data <br /> S 'd 1619 'ON Nlti 11 9101 '01 '110 <br />