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RECEIV 8080 "N WdH :9 LIE '8 'qad ;W1J pania)ad <br /> E2 _ _ <br /> �E� 0 <br /> CITY OF MANTECA WQCF <br /> ROP � ti— <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> PE►'� <br /> I. PRODUCER OF LIQUID WASTE pH <br /> NAME �� P ��S ,_ PHONE <br /> PICK-UP ADDRESS_ � C;_�O <br /> Number Street City State Zip <br /> WASTE SAO -- DOMESTIC WASTEWATER ONLY from(circle one): <br /> Septic Tank Portable Toilet Other(describe) <br /> PICK-UP DATE _�i��--\:2 TIME t �� QUANTITY als <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated. <br /> �c v' AAA NA ­ I <br /> Printed Name of Owner,Occupa t or Agent SignAture of Owner,Occupant or Agent <br /> 2. HAULER <br /> NAME ROTO-ROOTER- Stockton <br /> BUSINESS ADDRESS 4228 Newton Road Stockton CA 95205 <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. Vehicle Lice No _-1 '�•� 1� <br /> / <br /> James Sanders C- <br /> Printed Name of Hauler ignature of Hau er <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave., Manteca, CA 95337 <br /> 1 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 Ueei i�StationPermit_ <br /> Sig a re of Waste Facility Operator <br /> DATE I (� TIME IN-'& m TIME OUT NET QUANTITY72� 6 Rals <br /> Rcv.02/09 office assistant/septic deliveries and data <br /> ti 'd I IOL '°N Adtiti 9 L10Z 8 q <br />