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L2WON Wd9E :5 9102 Zl ')aQ6!°aw1l�p4AI- ; ad <br /> CITY OF MANTECA WQCF <br /> 'W'ASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LI UTA WASTE p}'I <br /> CSG <br /> NAME S _ PI4ONE� <br /> PICK-UP ADDRESS /LUQ D. CTCL�f(R Nj ►GPI C- 44 A <br /> Number Street City ' State zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): <br /> =Tank Portable Toilet Other(describe) <br /> PICK-UP.DATE_&�,-// /�,/, TIME 12L QUANTITY_�T�A �alS <br /> I e ifyAtha�,this w ste was delivered to the hauler named below for le al disp at mite indicate <br /> Printed Name of Owner,Oec pant or Agent Sig tura of Owner,Occupant or Aa t <br /> 2. HAULER <br /> NAME ROTO-ROOTER - Stockton <br /> BUSINESS 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 /> G <br /> Receiving Station Permit No. / Vehicle License No149s:�rlval <br /> 17 <br /> Roosevelt Moore _ <br /> Printed Name of Mauler Signature of Hauler <br /> 3. RECEIVING S'T'ATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave., Manteca, CA 95337 <br /> I certify that the hauler above delivered the described liquid waste to tbl�ispo al facility,and at it s <br /> accepted/rejected (circle one)material under the terms of the bete; g St o �ermit_ <br /> Siglnature of Waste Facility Operator <br /> DATE. TIME IN TIME OUT NET QUANTITY <br /> Rcv,02/09 office assistant/septic deliveries and data <br /> 'd N99 'ON Md S 9102 z � Baa <br />