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tiH IN AVH :6 21H '6 add ;Wli paAl ;);� <br /> CITY OF MANTECA W CF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUC;.R OF LIQUID WASTE pg � <br /> NAME I LO'S CCC' PHONE atg - C)8� `J i <br /> PICK-UP ADDRESS 1 ,`( 030 <br /> Number Street City State Zip <br /> 1VASTE SOURCE: DOMESTIC WASTEWATF-k ONLY from(circle one): Septic Task Portable Toilet <br /> PICK-UP DATE 03 a o t S TIME 2pb QUANTITY als <br /> I certify that this wast s delivered to the hauler named below for legal 'sposal the " in ated. <br /> Printed Na4 of Owner,Occupant or Agent Sit natur eeupant or Age <br /> 2. HAULER <br /> NAME Roto Rooter <br /> BUSINESS ADDRESS L4-U 43 f),ffx� Vgt a�L A 6+-04t�rl G A (51 15 C?-o5 <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 Incense No. <br /> Printed Name of H er Signa re of Orwer <br /> 3. RE-C)EfYING STA.T>CQN <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 /> Si r of Wa to Facility Operator <br /> l �} <br /> DATE r'` I U TIME IN '�L� TIME OUT NET QUANTIT��?':�— gals <br /> Rev.02/09 office assistant/forms <br /> ti 'd 6266 'ON AVS l : 6 91H '6 'add <br />