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otiti98 ' N WdZS �O l S l O '9 A�W aui1 Panima <br /> � <br /> CITY OF SEC +�' f <br /> A,W CF <br /> WASTE 11AULF-VIS SOURCE CERTIFIC.A.TION <br /> A1. PRODUCER OF LIQ ID'oVA,STE <br /> NAME PHONEI� <br /> PICK-UPADDRESS l63r L ^` s <br /> Number Street Citzip <br /> y tate <br /> WAS'T'E SOURCE::/DOMESTIC WASTEWATER ONLY from(circle one): eptPortable ToiletPICK-UP DATE `f` " G J�' �'� ic T _ <br /> QUAT�STITY ���� <br /> I certify tbat this waste was delivered to the hauler named below for legal disposal at site indicated <br /> Panted Name of Owner,Occupant or Agesx# S Mature of Omer,Occupant or <br /> P Agent <br /> 2. GT R <br /> NAME koto Rooter <br /> 13USDMSS ADDRESS i 2 <br /> Number Street City State zip <br /> I certify that the desc"bed waste was hauled by me to the disposal facility named below: <br /> r <br /> Receiving Station Permit No. J Vehicle License No. <br /> ca_�L i <br /> Printed Name of Hauler Signature of H4uler <br /> 3- RECEBTiG STA JON <br /> NAME AND ADDRESS_ City of Manteca WQCF 2450 Nest Yore dW Ave. Mauteca,.CA 95337 <br /> i <br /> I certify that the hauler above delivered the descn'bed hquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material wader the terms of the Receiving Station Permit <br /> Signature o£"'ki'aste Facility operator <br /> DATE y TIME IN . TIlME OUT —NET QUA=Y__-, '3 mals <br /> i <br /> Rev.02/09 office assistaut/f= <br /> ti d ti9lz '�N <br /> NOd : 01 SIH '9 ��W <br />