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ZILI 'nN NV�� :9 L10Z '6I •unr ;WI J paniauad! <br /> i <br /> CITY OF MAMCAW CF ",top <br /> WASTE HALUR'S SOURCE CERTIFICATION <br /> 1. P UCER OF MUED WASTE <br /> ell <br /> PICK Sl Z S / �(Gey L� „1 l �T f �� A C' <br /> Number Street City State Zip <br /> WASTE SOURCE:-DOMESTIC WASTEWATER ONLY from(circle one): Septic Tank Portable Toilet <br /> PICK-UP DATE 0 7 TlA2E � Z � __ QUANTITY' g <br /> I certify that this waste was delivered to the hauler named below for legs; - sa1 at site iadicatcd. <br /> Printed Name of Owner,Occup or Agent Egnatnre of ,Occapant or Agent <br /> i <br /> 2. HAULER ! <br /> NAME Roto Rooter <br /> BUSINESS ADDRESS `1-2,—,> F n e C'4C -Rci� L-kCC.S`--3 <br /> Number Street City State Zip <br /> I certify that the descn'bed waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No. Vehicle J.;cense No.-7 ��' rCS�' r <br /> Printed Name of Hauler Signature of Hier <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,CA, 95337 <br /> ! <br /> I certify that the hauler above delivered the deembed liquid waste to thiS disposal fhci ty,and that it was <br /> accepted/re*ted(circle one)material under the terms of the Receiving Station Permi <br /> • i <br /> ignature of Waste Facility O ator <br /> i <br /> r <br /> DATE d iZ TIME IN OUT �� NETt UANTrry G <br /> Rev.07J09 office w st=lfMW <br /> ti 'd Z16L 'ON Wd00 : 6 LIE '6I 'unr <br />