Laserfiche WebLink
M [ 'ON M60 :ti 9102 Z1 'd;Q a.uil Paniaaa� <br /> CITY OF MANTECA WQCF . <br /> WASTE IrAULER'S SOURCE CERTIFICATION <br /> L PRODUCER OF LY UID WA TE pH <br /> PHONE�K <br /> T , <br /> .PICK-UP ADDRESS <br /> Number Street City State Zip <br /> WASTES OMESTIC WASTEWATER ONLY from(circle one)_ <br /> t/Septic Tan • Portable Toilet Other(describe) <br /> PICK-UP DATE to Trl QUANTITY_ E��15_ <br /> _teals <br /> I certify that this waste was delivered to the hauler named Belo" f r Iegal disposal a e site indica ed_ <br /> 1 - <br /> Printed Name of Owner,Occupant or Agent signature of owner, ccupant or Agent <br /> 2. HAULER <br /> NARE ROTO-ROOTER- Stockton <br /> BUSINESS ADDRESS 4223 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 /> Receivin'Station Permit No. ✓� Vehicle License No <br /> Roosevelt Moore <br /> Printed Name of Mauler Signature of Hauler <br /> 3. RECEIV LNG STATION <br /> NAS AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave., Manteca, CA 95337 <br /> I 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 cStation Permit. <br /> Signayuje of Waste Facility Operator <br /> DATE 0 �� TIIE XN I °� �1 THE OUT 'MET QUANTITY3�/_Rals <br /> Rom.02/09 office assistant/scptic deliveries and d= <br /> E 'd SS6S '°N Wdll :ti 9102 '6l 'daS <br />