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M�Dl3 � HIVON 09 : 11 9101 '01 ';I0 IWIJ paniaD;� <br /> CITY OF MANTECA WQCF 9 <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LI UID WASTE pH-6, ` <br /> NAM) <br /> PICK-UP ADDRESS_ ?0,3U S Irl � C• �a ,roP _ �S3 o <br /> Number Street City State Zip <br /> WASTE SOUR - DOMESTIC WASTEWATER ONLY from(circle one): <br /> ptic Ta Portable Toilet Other(describe) <br /> PICK- DATE �T TTN E �C1; QUANTITY' � � als <br /> I certify that this waste was delivered to the hauler named below f legal disposal at a site dicated. <br /> r <br /> Printed Name of Owner, ccupant 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_ Vehicle Ycense No / <br /> Roosevelt Moore <br /> Printed Name of Mauler Signature of Mauler <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS= City of Manteca WQC?~ 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 Re eivina Station Permit. <br /> Signa r of Wa a laacility Operator <br /> DAT I / �� TIME IN I `� TIME OUT NET QUANTITY 33 ---gals <br /> Rev.02/09 ofcc assistendseptic deliveries and data <br /> d 1619 'IN Wdlti 9102 '01 '110 <br />