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9960 "N Wdl l 5 9102 '� [ 'ln� ;W1J paniF)a <br /> CITY OF MANTECA WQCF _-3) J , <br /> WASTE HAULER'S SOURCE CERTIFICATION 1� <br /> I. PRODUCER OF LIQUID WASTE <br /> NAN18 i ��:SC�Q. PHON�"5 <br /> PICK-UP ADDRESS 19-03D S , t✓IC�r��h <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): <br /> Jc Ta - Portable/Toilet Otber(describe) <br /> _epi <br /> PICK-UP DATE__Sp ��/S� TIVI QUANTITY teals <br /> I certify that this waste was delivered to the hauler named below for legal disposal at a site indicated_ <br /> m�x�da- 9�'� (&,�. <br /> Printed Name of Owner, Occupant or Agent Signature of Owner, Occupant or Agent <br /> 2. HAULER <br /> NAME ROTO-ROOTER- Stockton <br /> BUSINESS ADDRESS 4228 Newton Road Stockton CA 95207 <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 se No r <br /> n <br /> Roosevelt Moore <br /> Printed Name of Hauler Signature of Hauler <br /> 3. RECEINTNG STATION <br /> NAME 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.uader the terms of the RS tion Permit- <br /> Signat re f ante Facility Operator <br /> _..-.. DA.T _ <br /> Rcv.02/09 office assistant/septic deliverics and data <br /> ti 'd ESS "N Adtil :S 9l0l '6l 'lnr <br />