Laserfiche WebLink
6W "N &66 :e 9M '6 'qaj aWli pani-a�- <br /> CITY OF NvL4NTECA WQCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> I. PRODUCER OF LY !1-]:U WASTE pII <br /> f r� r . <br /> NAME_ L`� .SSL' CcL�L F,{ P14ON <br /> PICK-UP ADDRESS_ ,Q(%j-30 <br /> Number Street City State Zip <br /> WASTE SO - DOMESTIC WASTEWATER ONLY from(circle one): <br /> (S�C �fan�'y /)portable Toilet Other(`describe) `` <br /> PICK.-UP DATE /!/ // TIME / �`^� QUANTITY �1 .. _._.gals <br /> I certify that this waste was delivered to the bauler narncd below for A-dispthe site indicated. <br /> Printed Name of Owner,Occupant or Agent SignaOccupant or Agent <br /> 2. IfAULER <br /> NAME ROTO-ROOTER- Stockton <br /> BUSINESS ADDRESS 4228 NeNNtoii 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 /> Reociving Station Permit-No, Vehicle License No <br /> Roosevelt Moore <br /> Printed Flame of Hauler Signature of Hauler <br /> 3. RECET"NG STATION <br /> NAME AND ADDRESS_ City of M=teca 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 tinder the terms of the Receiving Station Permit. <br /> 'Sionaiai�1of Waste Facility Operator <br /> r <br /> DATE_L_ TINM IN_ �'� fy TIME OUT NFT OANTfTY gals <br /> Rev.02109 office ass tant/acp6;;dclivcdcs and data <br /> Z 'd 19D '°N Agd :0 9106 6 qad <br />