Laserfiche WebLink
May ' 1 °2016 11 : 09AM No. 4985—�(P, 2 <br /> r <br /> CIT-17 OF NIANTECA -vVQCF <br /> WASTE ffikULER S SOURCE CERTIFICATION <br /> 1.. PRODUCER OF LIQUID WASTE pH - ' <br /> PHON1= . 4� / . <br /> PICK-UP ADDRESS 1 S S r Ala C l e—lkl <br /> Number Street city State zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle Une): <br /> Septic Tan Portable Toilet Other(describe) <br /> PICK-UP DATE TIME Z 6' QUANTI-fY gals <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site ' dicated. <br /> Pr Name of Qv�u r,Occupant r Agent Signature of Owner,Oe c pant or bent <br /> 2. HAULER <br /> NAMEROTO-ROOTER- Stockton <br /> BUSINESS ADDRESS. 4228 Newton Road Stockton CA _ 95205 <br /> Nznuber 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. ✓ �. r <br /> Veb,icle License No . <br /> Roosevelt Moore --- _ <br /> Printed Name of Mauler Signature of Hauler <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave.. Manteca,CA 95337 <br /> 1 ceziify 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 Receiving Station.Permit. <br /> Signa re of Waste Facility Operator <br /> 1]A t1 <br /> U 'i'IME IN,_.�f `I"lME OUT NET QUANTiTY� � Lyals <br /> Rev.02/09 office assistant/septic del iverins and data <br /> Received Time May, 3. 2.016 11 : 05AM No. 0757 <br />