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9690A MD :S 9l0 , dV ,;wail paA`"TO <br /> CITY OF MANTECA WQCE <br /> WASTE HAUEER'S SOURCE CERTfflCATTON ALM <br /> 1. PRODUCER OF LIQUID WASTE pH ' <br /> NAME__ 86' e S C.C_ll!f'. PHO <br /> PICK-UP ADDRESS A?6310 �� ff /�.� L4ACBn �3�s <br /> Number Street City State Zip <br /> WASTE S4UR MESTIC WASTEWATER ONLY from(circle ane): <br /> Septic Tante „Portable Toilet Other(describe) <br /> 00, <br /> PICK-UP DATE. TTW, QUANTITY 3-2 10Z� <br /> I certigy that this waste was delivered to the hauler named below for legal disposal at the site indicated. <br /> Printed Name of Own ,Occup t or Agent Signature of Owner,Oc pant;Tient <br /> 2- HAULER <br /> NAME ROTO-ROOTER - Stockton <br /> BUSINESS ADDF FSS 4228 Nevvton 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 No.. +e Vehicle License Nos��? _ 7 <br /> Roosevelt Moore <br /> Printed Name of Hauler Signature of Hauler <br /> 3. RECEIVING STATION <br /> NAIVE.AND ADDRESS: City of Manteca WQCF 7450 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 the Receivir+g Station Permit. <br /> r' <br /> •-`Signature oti-'VGaste Facility Operator <br /> DATE `f IME OUT IN., •.; _, ..:.., <br /> w TIME -' . <br /> - _.. . NET QUANTITY_ <br /> - gals <br /> Rev.02/09 ofice assistant/scptic deliveries and data <br /> 'd MZ 'ON Wd Lti :S 9102 '�l 'a dy <br />