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r H0 'IN AVSZ :6 2l0Z Zl 'A PN a JI J pzAi6(v aaa� <br /> CITY OF MAN'TECA W CF J f <br /> WASTE HAULERS SOURCE CERTIFICATIQN <br /> I. PRODUCER QF LIQUID WASTE pH - — <br /> PHONE' — <br /> PICK-UP ADDRESS �5 <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): Septic Tank portable Toilet <br /> PICK.-UP DATE- �� TIME ` � � � QUANTITY- als <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated_ <br /> Printed Name of Owner,Occupant or Agent ignature o Owner,Occupant or Agent <br /> 2. HAULER <br /> NAME Roto Rooter <br /> BUSINESS ADDRESS <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. C�:,1 Vehicle License No_ <br /> - <br /> Printed Name of Ha er ature of Ha er <br /> 1 RECEIVING 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 Receiving Station Permit. <br /> 1 <br /> Signa a of Waste acilitq Operator <br /> DATE I I U TR M IN`3 OS�� TIME OUT NET QTJANTITr� gals <br /> Rev.02/09 office assistant/fo= <br /> ti 'd M6 'ON NVK : 6 91H <br />