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9690 "N AdD :S 9106 �l 'add—awil paniaaa� <br /> CITY OF MAINTECA WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION � <br /> 1. PRODUCER OF LIQUID WASTE pH <br /> NAME iSe, <br /> PICK-UP ADDRESS /r Q3a S r _- _ r��f�,—a�a �, �'•��.��a_ <br /> Number Street State Zip <br /> WASTE SOURCE; DOMESTIC WASTEWATER ONLY fi m(circle one); <br /> C:::�S6iicTai_nil, Portable Toilet Other(describe) <br /> PICK-UP DATE _ / TIME �` G QUANTITY 4C, ryals <br /> I certify Pat this waste was delivered to the hauler named below fbr le1al d sposai at the <br /> site iodic d. <br /> Printed Nalne orOwne Occupant Agent Siguatu of Owner,Oce t or Agent <br /> 2. . HAULER <br /> NAME ROTO-ROOTER- Stocktaa <br /> BUSE'4ESS ADDRESS 4228 Newton Road Stockton CA 95205 <br /> Number Street City State Zip <br /> 1 certify that the.described waste was hauled by the to the disposal Facility named below. <br /> Receiving Station Permit No. Vehicle License No <br /> _Roosevelt Moore <br /> Printed Name of Hauler Signature of Hauler <br /> 3. RECETVING STATTOIN <br /> NAME AND ADDRESS'. City of Manteca WQCF 2450 West'Yosemite Ave_, Manteca,C.A, 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 Receiving <br /> /Station <br /> Permit. <br /> Sigonature of Waste Facility Operator <br /> DATE =�C� TINIlr IN_/� � TIti'IE OUT NET QUANTITI teals <br /> —� <br /> Rev.02/09 o fficc assistant/septic delivcrics and data <br /> 'd HO 'IN Ad9�:� 9106 'E l 'add <br />