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Z9ti0 'ON Nd6Z :E 9102 '6 q;j aw11 Pani ;°;d ' <br /> CITY OF MANTECA WQCF <br /> WASTE HAULF RIS SOURCE CURTIFICATION <br /> 1. PRODUCED OF LI UID WASTE C pH f <br /> NAME �.S G P. PIIONE—, <br /> PICK-UP ADDRESS /--2J-7 - c -j I-L <br /> Number Street City Slate <br /> WASTE SOCA ONIESTIC WASTEWATER ONLY from(circle one): <br /> eptic Tank , Portable Toilet Other(describe) <br /> PTCK UP DAT 1� 1� QUANTITY .s� � <br /> .� :=gals <br /> I certify that this waste was delivered to the hauler named below for legal sal at the site indicated. <br /> Printed Name of Owner,Occupant or Agent Signj toe Owner,Occupant or Agent <br /> 2. HAULER <br /> NAME ROTO-ROOTED-Stockton <br /> BUSYNESS ADDRESS 4228 Newton 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 /> A r �. <br /> Receiving Station Permit No_ a� r Vehicle L' nse No 7/7714/�.� <br /> Roosevelt Moore - <br /> Printed Name of Hauler Sigx�atiire of Hauler <br /> 3. RECENING STATION <br /> NAME AND ADDRESS: City of Manteca WQCP 2450 West Yosemite Ave., Martteca, CA 95337 <br /> 1 certify that the hauler above delivered the descn-bed Uquid waste to this disposal facility, and that it was <br /> accepted/rejected (circle one) material uuder the terms of the R i m<g.Station Pe <br /> Signature of,Wdste F eilrty Operator <br /> DATE { -r 4 s "TTIvM W r TIME 171.JT__ ��i:' �T QC3ANTITY als <br /> Rev.02/04 ofx uc assktant/scptic deliveries and data <br /> 9l0Z '6 q <br />