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i <br /> tiHFIN 9l0Z '9 'U. r awil Pani ;D;� <br /> CITY OF NUNTECA WQCF <br /> WASTE ILA.ULER'S SOURCE CERTIFICATION <br /> t. PRODUCER OF LIQUID WASTEpI-I <br /> a <br /> NAME 4. � ���.Cc P; FHO _ G Rll 7^. <br /> PICK-UP-ADDRESS <br /> Number Street City State Zip <br /> 'W'ASTE SOURCE: DOMI ESTIC WASTEWATER ONLY from(circle one): <br /> =1sepfi- <br /> _" Portable Toilet Other(describe)__,._._._._____ <br /> PICK-UP DATE Z l TIM <br /> E QUANTITY r "7 -a1s <br /> [certify that this waste was delivered to the hauler flamed below for levalr ispc 5aI atth fps�indicate . <br /> . <br /> Printed Nance of Owner,Occupant or Agent Signature of Owner,Occupant or agent <br /> 2.. HAULER <br /> NAME RO O-ROO'MR- 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 <br /> by me to the disposal facility earned below- <br /> Receiving Station permit No. 7,2 l Vehicle Li ease No <br /> Roosevelt Moore <br /> Printed Nance of Hauler Signature of Hauler <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave., Manteca, C.4. 953'7 <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 th ceivinv Station Perrnit- <br /> a <br /> Slgwatu east Facility Operator <br /> DATE � S TIME 1N 1 TIME UIJ"C NET QUANTITY _3P'_2gals <br /> Rev.02/09 office assistandseptic deliveries and data <br /> 'd z0 [ti 'ON WdLz : Z 9l0Z '9 'UPS <br />