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5980 'ON AdH :S 9 l 0 '9 'ung ;W'I! 'pan 1 ;0 <br /> CTTV OF MANTECA WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION U <br /> I. PRODUCER OF110111D WASTE <br /> NAME t 11-501-- d3e Y, <br /> PICK-UP ADDRESSVfD,?e_-D <br /> _iZ_mber Street City state zip <br /> WASTE SOLU <br /> 4C&!;,DOMESTIC WASTEWATER ONLY frorn(circle oue): <br /> optic T Portable Toilet Other(describe)-- <br /> PICK-UP DAT TIME QUANTITY JZE1___* <br /> I cert' <br /> that this waste was delivered to the hauler named below for legal disposal at the site indicated. <br /> Printed_Name ofOwn r,Accu ant orAgent Signature of Owner ccupa r Agent <br /> 2. HAULER <br /> NAW, ROTO-ROOTER-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 by me to the disposal facility named below. <br /> Receiving Station Permit Na_ <br /> Vehicle Liceuse No <br /> Roosevelt Moore <br /> Printed Name of Hauler Sinatu,fe­of Hauler <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave., Manteca, CA 953371 <br /> I certif <br /> .y 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 e e I ivi g S1 tion Permit _7 <br /> Sig�L4�t �roWaste Facility Operator <br /> DATE TIME IN TIME OUT NET QUANTITY33E-2— gals! <br /> Rev.(P-/09 uffict:zissistant(septic deliveries and dafA <br /> 'd MS 'ON AdE6 :S 9�06 s 'unr <br />