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ti099 'ON WdLti: [ til0l '9l lnr 1 pania0ad <br /> ...4 Z4 <br /> CITY OF MANTECA WQCF <br /> WASTE HAULER'S_SOURCE CERTIFICATION <br /> I <br /> . i <br /> )$�UCER OF LIQUID WASTE PH <br /> -UP ADDRESS <br /> Number^ Street City e zip <br /> 3TE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one), Septic Tan Portable Toilet <br /> -UF DATE '/G TIIv1E �' QUAN rrY 9 � als <br /> —, <br /> dfy that this waste was delivered to the hauler nam d below£or le=disposalaEdices <br /> ted Name of Owner,Occgpant or Agent ccupant or Agent j <br /> HAULER <br /> 11 Roto Rooter <br /> rNa:ss AVDltlrss �� S <br /> �umber� street city $tate ZzP <br /> I <br /> tify that the dawn-bed waste was hauled by me to the disposal facility named below. <br /> ^�- / �- <br /> �iving Station Permit No. � � Vebacle License No✓/ .�4� � <br /> f <br /> ted Name of Hauler Signa a of Hauler <br /> t <br /> RECEIY)C1YG STA'J<'�O�i <br /> 4E AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,CA 95337 <br /> day that the hauler above delivered the described liquid waste to thisdisposal t it <br /> pted/rejected(circle one)materW under the terms of-the Receiving Station P <br /> I <br /> Signa a of Wase Facility perator <br /> I <br /> E— TIME IN ��� rM TIME OUT / k1 NET QUANrrrY' X38 a>s <br /> Ir <br /> )Joel ofnct assismtlfo= <br /> . i <br /> 20/LO 391d Z13100�1 0101 9Z6559V60Z TS:ZT VTOZ/9T/L0 <br />