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ti�LL '�N AHU :6 8l0l 6 'add zwil pzniaaz� <br /> #7 <br /> CITY OF MANTECA WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> L PRODUCER OF LIQUID WASTE pH -6 - 3 <br /> NAME j3,0 i a2 C-0-S Cl-,,Cl PHONE `I <br /> PICK-UP ADDRESS I � /[2 .14 Com-r LL-. =kk � �LL-1-F C� Rq S- <br /> �� <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): Septic Tank Portable Toilet <br /> PICK-UP DATE_ 03 - 3- I TIME C} . .3O QUANTITY 32 9 gals <br /> I certify that this waste was delivered to the hauler named below for legal di sal at the site iodic <br /> Printed Nadne o Owner,Occupant or Agent Sign r o , cupan <br /> 2. HAULER <br /> NAME Roto Rooter <br /> suslNEss ADDRESS r6,� qSZC� <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. -7 Vehicle License No. . -7 <br /> 14 YA4,C- <br /> Printed Nam of Hauler Signature auler <br /> 3. RECEIVING SWAT ON <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,CA 95337 /7� <br /> I cern that the hauler above delivered the described liquid waste to this disposal facility, ` <br /> certify q p ty, and that it was <br /> accepted/rejected(circle one)material under the terms of the Receiving Station Fe 't, <br /> Sign re of aste)Facility Operator �l <br /> DATE ' TIME IN TIME OUT NET QUANTITY5��s gals <br /> Rev.02/09 office assistant/forms <br /> d 6266 'ON AHS l : 6 8l O '6 'add <br />