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9690 'ON AdEti :9 910 '�Ody ;wii paAI ;Dad <br /> CITY OF MANTECA WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION 40 Apom <br /> 1. PRODUCER OF.LI I i WASTE pH <br /> NAME S �►Y"l sf �e Iter PHONE � <br /> PICK-UP ADDRESS 1 � ! 41 <br /> Number Street City State zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): <br /> optic Tan l- Portable Toilet Other(describe) <br /> TIME,,,,,„ T QUANTITY <br /> —„_��„ <br /> I certify that this waste was delivered to the hauler named below for legal disp sal at the site indicated. <br /> 61 <br /> � r <br /> Printed Name of tivner,Occ pant or Agent Si;aatur of O er,0&upant or Agent <br /> 2. ElAULER <br /> NA1kQ: 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 hauledbyme to the disposal facility named below. f <br /> Receiving Station Permit No. " / Vehicle License No1� <br /> Roosevelt Moore <br /> Printed Name of Mauler Signature of hauler <br /> 3. RECEIYiNC 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 under the terms of theceivin Station Permit. <br /> a " "-- <br /> i <br /> Sigu�u' of Waste k acility Operator <br /> 9 <br /> ✓ i�� ; ; TIME IN '•��. 0 , TIiv1E UUT ,��� NET UANTITY <br /> DATE <br /> -- — �.��.._— 4 '� gals <br /> itcv.02109 nffae assistanVsepiiie deliveries and data <br /> z d gzgti '�N Ad9�:5 9106 'e� 'add <br />