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9960 "N Wdll : 9 9 [0Z � l 'lnr avail" pariiaa;�J <br /> CITY OF NL kNTECA WQCF l �� <br /> WASTE MAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LIOUCD WASTE pH O <br /> NAND D S PRONE <br /> PICK-UP ADDRESS �Tzip Number Street Cityto <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): <br /> u Tank Portable Toilet Other(describe) <br /> PICKUP DATE TIME QUANTITY gals <br /> I certify that this waste was delivered to the hauler named below f legal dispos indicated, <br /> cff�c�& Qn� ) <br /> AL <br /> Printed <br /> Name of Owner,Occupant or Agent S'b lure of Owner,Occupant or Agent <br /> 2. ILA ER <br /> NAME ROTO-ROOTER- Stockton <br /> BUSINESS ADDRESS 4228 Newton Road Stocktom CA 95205 <br /> Number Street City State Zip <br /> I ceztify that the described waste was hauled by me to the disposal facility named below. c <br /> Receiving Station Permit No. / Ve le LiC nse No F <br /> Roosevelt Moore <br /> Printed Name of Mauler Signature of.Hauler <br /> 3. RECEIVLNG STATION <br /> NAME AND ADDRESS: City of Manteca WQC;✓ 2450 West Yosemite Ave., Manteca, CA 95331 <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility, and that it was <br /> accepted/rejected(circle ore)material wilder the te-ims of the ceivi �Stag Permit. <br /> Sig e o a e Facility Operator <br /> DATA TIME TN_V TTMFT NFT��IF� � gs -- <br /> Rev.02/09 office assistmt/septic deliveries and dam <br /> z 'd ESS "N WdEl ; s 91H Tir <br />