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ZIWIN ft�5 :S LIH 'Wunr awil pania)a <br /> crrx of MArrrEca w cF <br /> �1 :► <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. MDUCER OF LIOUID WASTE g <br /> NAME O -�H�N�) �G <br /> PICK-UP ADDRESS C) C) S A I-�OL 01 <br /> Number Street City state, zip <br /> I <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): Septic Tank Portable Tofier <br /> PICK-UP DAVE 4 2 QUANTITY <br /> I certify that thb waste was deHverp4 to the hauler named below for legal dis>osal at the si a indicated. <br /> Prated Name of Owner,Occup'hit or Agent igpature of er,Occupant or Agent <br /> I <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. -l__ �'( Vehicle License No. C <br /> Printed Naine of Hasler Signature of Hoa <br /> r v , <br /> i <br /> 3. RELF4MG STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,-CA 95337 <br /> _ .I <br /> I certify that the%auler above delivered the described liquid waste to this disposal ficili <br /> qui disp ty,and that it was � <br /> accepted/rejected(circle one)material under the terms of the Receiving n Permit_ <br /> 'i <br /> Signature of Waste Facility Operator <br /> i <br /> DATE Thug IN I l l TIlKE OUT_ � <br /> L -NET Q(lANTTTy <br /> Rev_02/09 office assi5mnvforW I <br /> Z ZI6C ' Wd00 :6 LIH '6I 'ung <br />