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tiEU "N &H :6 81H '6 'ady ;W!j pania3q <br /> CITY OF NLkNTECA 'WQCF 9 <br /> WASTE I-IAULER'S SOURCE CERTIFICATION I c) 6- <br /> 1. PRODUCER OF LIQUID WASTE pI{ ' <br /> NAME C 5�.. . 4 C' �; PHONE <br /> PICK-UP ADDRESS <br /> Number Street City State�— Zip <br /> r WASTE SOURCE DOMESTIC WASTEWATER ONLY from(circle one): <br /> i"'Septic <br /> TAO.-- Portable Toilet Other(describe) <br /> PICK-UP DATE G' - I `J TIME_ QUA TY �_ gals <br /> I certify that thistiwaste vas delivered to the hauler named below for lega a indicated. <br /> Printed Na e o Owner,Occupant or Agent Signa r ner,Occupant or Agent <br /> � r <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 Licen No <br /> James Sanders �r - <br /> Printed Name of Hauler ��ignature of Hauler <br /> 3. RECEIVINd 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 Re n St tion Permit. <br /> Signatur of Waste Facility Operator <br /> DATE 3 �I� I U TIME IN 16' TIME OUT NETUANTITY�� als <br /> —.�s <br /> Rev.02/09 office assiscsnt/scptic deliveries and data <br /> Z d 6166 "N MH :6 "'810Z '6 'A dy <br />