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RECEI `0 <br /> 2020 "N Wd88 9 LIE '2 qad quail paniaaad <br /> FE8 0 9 2017 CITY OF MANTECA'WQCF l <br /> MV <br /> POWI FROM WASTE HAULER'S SOURCE CERTIFICATION <br /> pE{+�d11T/S�� — <br /> r <br /> 1. PRODUCER OF LIOUTA WASTE pH <br /> NAME <br /> PICK-UP ADDRESS C. '. U r J c� <br /> Number Street City State Zip <br /> W CE: DOMESTIC WASTEWATER ONLY from(circle one): <br /> SepticTank Portable Toilet Other(describe) <br /> PICK-UP DATE - T TIME <br /> _ �-1 QUANTITY —72 als <br /> I certify that this waste was delivered to the hauler named below for legAl disposal m th ' indicated. <br /> 001WJLA <br /> Printed Name of Owuer,Occupant(W 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 rhe described waste was hauled by me to the disposal facility named below_ <br /> Deceiving Station Permit No._ ] —_ 1 Vehicle License N I G <br /> James Sanders <br /> Printed Name of Hauler $jg ature of Hauler <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 Rec wing Station Permit. <br /> Sijprture of Waste Facility Operator <br /> DATE__L TIME IN 'f TIME OUT NET QUANTITY�_ 1 gals <br /> Rav,02/09 office assistant/septic deliveries and data <br /> 8 'd I I0L 'ON Wdtiti :9 LIR '8 q <br />