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ti099 •ON Adjti: [ tiI.oZr -91 lnr .wii pant 0 <br /> � II <br /> - f <br /> I <br /> CITY OF MANTECA WOCF <br /> WASTE HAULER'S SOURCE CERTIFICATION f <br /> i <br /> i <br /> PRODUCER OF LQU WASTE W H <br /> P , <br /> PHON 0,7 <br /> -UP ADDRESS <br /> Number Street City State Zip ! <br /> i <br /> 3TE SOURCE- DOMESTIC WASTEWATER,ONLY om(circle o Septic Tank P*stable Toilet <br /> -UP DATE �� I 1 TIME ' QUANTITY' gals <br /> i <br /> tify that this waste was delivered to tate hauler named below for legal disposal at the site indicated I <br /> a4_4j�, _ 9/6 vcvlk�� i <br /> ted At6e of Owner, ec aAt or Alt Signature of Owner,Occupant or Agent <br /> HAULER <br /> Roto Rooter ! <br /> INESS ADDRESS 2� � � IZu S-Ki4.Km��__ <br /> �N'u6ber Street City State Zip <br /> t <br /> af5'that the described waste was hauled by me to the disposal facility named below. <br /> iving Station Permit No_ � Vehicle License No <br /> 4L ­&L�ted Name of Hauler Signature of Haulir - f <br /> I <br /> RECEnT STATION <br /> 4E AND ADDRESS: City Q of Manteca W CF 2450 West Yosemite Ave. Manteca,CA 95337 <br /> I <br /> afy that the hauler above delivered the described liquid waste to this disposal facZ t was <br /> pted/rejected(circle one)material under the terms of-the Receiving S do " ! <br /> ' II <br /> Ugn <br /> ature of Waste acWty Operator j <br /> I <br /> I . <br /> E D / TMffi IN f TIME OUT NET QUANTITY ! <br /> . i <br /> f <br /> )2/0i_of,ca aAsi mnt/fotms <br /> L0/b0 39dd 2J=Oa 0102) 9Z6SS9b60Z TS:ZT t7TOZ/9T/20 <br />