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0HPIN MSS : 6 9 [0Z ll 'a W ;Wli pania);� <br /> CITY OF MANTECA WOCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LIOM WASTE pg <br /> NAME //PHONE <br /> PICK-UP ADDRESS \ 7 ,c �c ¢\ L r ,/l / 1b,.! <br /> Num er Street City t Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle oat): Septic Wank portable Toilet <br /> PICK-UP DATE QUANTITY _gals <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 Signa a of Ow�aer,Occupant or Agent <br /> 2. HAULER <br /> NAME Roto Rooter ` <br /> BUSINESS ADDRESS <br /> Number Street amity State Zip <br /> I certify that the described waste was bauled by me to the disposal facility named below. <br /> Receiving Station permit No. Vehicle Incense No. c' <br /> cp <br /> Printed Mame of Hauler azure of Healer <br /> 3_ R)ECEYVING 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 Stati Permit <br /> i <br /> Signa re of'Waste Facility Operator <br /> DATE �— l TITv1E XN ' b �_"l TTM)✓OUT NET QUANTITY3 ~U) gals <br /> Rcv.02/09 office assis=x/fomis <br /> z d M6 "N WHS� : 6 9102 <br />