Laserfiche WebLink
9690 "N MD :S 9102 '�[ 'a y awil pania0;� <br /> CITY OF MANTECA WQCF <br /> WASTE HALTLER'S SOURCE CERTIFICATION oil� <br /> 1. PRODUCER OF LIQUIII-WAST pH <br /> NAME &;.s e.. C,,s PHONE.6209 <br /> PICK-UP ADDRESS 1A0,30 <br /> S, arl�c�i ej. Z4fAfe L2 <br /> Number Street City State Zip <br /> WASTE SO : D�JMESTIC WASTEWATER ONLY from(circle one): <br /> Septic Tank: Portable Toilet Other(describe) <br /> PICK-UP DACE ! TiME 4.•7- QUANTITY, gals <br /> 1 certify that this waste was delivered to the hauler named below for lei l disposal at the site iU ted_ <br /> Printef r, eeur t Signature •of Owner,Oc ant or n <br /> d Name ocanepaat oAgent <br /> 2. HAULER <br /> NAME ROTO-ROOTER- Stockton <br /> BUSINESS ADDRESS 4223 Newton Road Stockton CA 95245 <br /> Number Street city State Zig <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No. ' ` " Vehicle License No �FT f9 <br /> i <br /> Roosevelt Ware ..-_ <br /> Printed blame of Hauler Signature of Hauler <br /> a. R:ECEWINC STAT ION <br /> NAME AND ADDRESS: City of Manteca- WQCF 2450 West Yosemite Ave., Manteca,CA 95337 <br /> 1 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 Receiving Station Permit. <br /> Signature of Waste Facility Operator <br /> DATE !I— `-P TIME 1N TINtE OUT—, NET QUANTITY gals <br /> Rev.02/09 office assistant/septic deliveries and dig <br /> 'd 2N8 'ON Ad9ti:S 9�0Z 'E[ add <br />