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2020 "N WdH :9 L10Z •9 -qad aW paniaaad <br /> CITY OF MANTECA W CF <br /> 11 STE HAULER'S S0 RCE CERTXFICATION <br /> I. PRODUCER OF LIQUID WASTE l pH <br /> NAME PHONE�c" <br /> PICK-UP ADDRESS <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): <br /> Septic Tank portable Toilet Other(describe) <br /> PICK-UP DATE Q TIME cl,� QUANTITY 9 w` als <br /> I c ify that this waste wa livered to the hauler named be;ig4nre <br /> al disposal at site indi d. <br /> Printed Name of Owner,Occupa or Agent 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 /> 1 certify that the described waste was hauled by me to the disposal facility named below- <br /> Receiving Station Permit No--c-1 — �. _ 'Vehicle License No <br /> James Sanders <br /> Printed Name of Hauler 1 gnature of Hauler <br /> 3. RECEI'V'ING STATION <br /> NAMI;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 ofth eceiving Station permit. <br /> Signa ure of aste Facility Operator <br /> DATE TIME 1N_LJ •�k� TIME OUT NET QUANTITY_�q_74 gals <br /> Rev.02/09 office assistandsepiic delivcric3 and data <br /> Z 'd l l0L 'ON WdW9 LAA '8 qad <br />