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f' - 0137 H [O 'ON AVK :: l 91E '0 10 1 W I J paniaaaa <br /> CITY OF MANTECA WQ CF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> I. PRODUCER OF LIQUID WASTE pH - <br /> NAME 1 1SC,11 . PHONE ��'� e,1//�1 --^- <br /> PICK-UP ADDRESS /�26f� y�. � �Q �, Gac - 33 0 <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): <br /> �ept-zk Portable Toilet Other(describe) / 1 <br /> PICK-UP DATE , 7 / TIW f QUANTITY vials <br /> I certify that this waste w delivered to the hauler named below fo legal disposal a site ' icated. <br /> Z" <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. <br /> Receiving Station Permit No_ f Vehicle Licens No <br /> Roosevelt Moore <br /> Printed Name of Hauler Signature of Hauler <br /> 3. RECEFVING 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 St t` it. <br /> Signature f W ste a Aerator <br /> DATE /� f e// i%, TIME IN TIME OUT NET QUANTITY ?3 gals <br /> Rev.02/09 officc assistant/septic deliveries and data <br /> ti 'd 1619 'ON Wd : [[ 9 �H 'E '}10 <br />