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HN 'IN AV01 :6 � [OZ '� °Sny awil Paniana� <br /> cc I�lE <br /> ASG p 5 2015 <br /> CITY OF MAN g W +CF <br /> ,,RONMENTALHEALTw - WASTE HA.ULELS SOURCE CERTIFICATION <br /> PERMITISER'j <br /> 1. PRODUCER OIi'LIOUID WASTE p$ <br /> NAME PFION42�a Cf/I <br /> PICK-UP ADDRESS LLti Irn U <br /> Number — - Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY fl=(circle ote)< epdic T Fortablt ToMt <br /> PICS-UPDATE �J .�T- T r QUANT= 3 <br /> _gals <br /> I certify tba#this waste was delivered to the hauler named below,for legal disposal at the site indicated <br /> Printed Name of Own ,Ocor Agent Sika of Uwner,Occup t or Agent <br /> 2. HAU7.ER <br /> NAME oto Roo <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 <br /> Receiving Station Permit No. _3 f Vehicle License No_ <br /> Z <br /> Printed Name of Hauler Sinare Cr <br /> 3. RECEYViNG STATION <br /> NAME AND ADDRESS: <br /> Cityof Manteca W <br /> QCF 2450 West Yosemite Ave_ Manteca,-CA 95337 <br /> I certify that the bauler above delivered the descnibed liq,IId waste to this disposal facility,and that it was <br /> acceptedlrejected(circle azsc)material under the terms of the Rer-eiving Statism P t <br /> U <br /> SWture m sste Facilitp Operator <br /> J <br /> lr7A7L5 Tam IN C9 Trn 4TT NET QUANTIT �� aLs <br /> P,=e_02/49 ofnoc assj�fmw <br /> I <br /> ti d �9H 'ON n <br />