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00H 'IN WHSZ :6 9l0Z aWli PaAl ;);d <br /> CITY OF MANTECA.WOCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> I. PROAUCER OF LT UID WASTE pg <br /> NAME 5 �C,A zS�'�,c� PHON-EO C7 ' C <br /> PICK-BJP ADDRESS <br /> umber Street City State Zip <br /> VVASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): Septic Wank Portable Toilet <br /> PICK-Up DATE l�— _T]ME� p, QUANTITY O <br /> gale <br /> 1 certify that this <br /> waste was delivered to the hauler named below for legal disposal at the site indicated. <br /> Printed Name of Owner,Occupant or Agent Signature of Owner,Occupant or Agent <br /> 2. HAULER <br /> NAME Roto Rooter <br /> 13USINESS ADDRESS c" � o� <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) ` _ Vehicle License N �1 <br /> Printed Name of auler attire of Hauler <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS: City ofManteea 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 e 't. <br /> f <br /> Sim a o� aste Facility Operator <br /> DATE TnvM IN Y�a M TIME OUT NETUAN`ITTY3� <br /> Q .eels <br /> Rev.02/09 office assismndforms <br /> 'd 9L96 'IN WdS� : 6 UH 'Zl " M <br />