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MO 'IN AdN :S 9[06 -2 'unp MIM P;AI ;0;� <br /> /'Vj L)1 <br /> CITY OF MANTECA -VVQCF <br /> (Z3 WASTE HAULER'S SOURCE CERTIF.IC.ALTIONI <br /> 1. PRODUCER OF L! Ulm WASTE <br /> PH <br /> NAME PHONE <br /> C <br /> PICK-kJPADDRESS__Z,Z6&C) <br /> Ig�2 <br /> A <br /> Number Street city State zip <br /> WASTE SOURCE. DOMESTIC WASTEWATER ONLY from(circle one): <br /> tic <br /> tic Tank rtable Toilet Other(describe) <br /> PICK- ATE_ <br /> T0,M <br /> QUANTITY <br /> tl., gals <br /> certify t <br /> at this waste was delivered t the}zanier named below for legal disposal at the site indicated. <br /> P -otewNsme of Signature of Owner, cC—U. <br /> ant or gent <br /> 2. 14AULER <br /> NAME ROTO-ROOTER- Stock-ton <br /> BUSINESS ADDRESS 4228 Newton Road <br /> Stockton, CA 05 <br /> Number Street City State Zip <br /> I certify that the described waste was laauled by me to the disposal facility named below. <br /> C?-9–/ <br /> Receiving Station Permit No. leA Vehicle License No <br /> Roosevelt Moor-, <br /> Printed Name of Hauler Signature of Hauler <br /> 3. R CE <br /> E TVING STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave., Manteca, CA 953;7; <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle oiic)material under the terms of the i ' si St tion Permit. <br /> Sig f <br /> 47� KasteioaLilliity Operator <br /> DATE_ 'rim-E ouT T QUANTITY <br /> NE gals <br /> Rev.02/09 office s55istant/tieptir,deliveries and data <br /> 8 'd 8M 'IN AdH : 9106 '8 "Ir <br />