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J pani <br /> HZ 0 "N 09E : 11 9102 '01 '1 01 a'JJiaaa� <br /> CITY Of MANTECA WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LI VID WASTE p <br /> PICK-UP ADDRESS <br /> Number Street City State Zip <br /> WASTE S OMESTIC WASTEWATER ONLY from(circle one): <br /> Septic Tank Portable Toilet Other(describe) <br /> PICK-UP DATE—6y — 16 TIME '::::) `, QUANTITY d dd als <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated. <br /> Printed Name of Owner,Occupant or 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 Lic nse No(O�7`-( yk <br /> James Sanders - <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 Receiving Station Permit. <br /> i <br /> Signatu of Wase]Facility Operator <br /> V <br /> DATE TIME IN V�' I U Lv TIME OUT NET QUANTITY gals <br /> Rcv 02/09 office ass iStan t/scptic deliveries and data <br /> Z 'd 1619 'ON Ndlti : l l 91H '0 10 <br />