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lStiFIN WdSl : � S10� -6 'add ;W1 j pania3;� <br /> i <br /> CITY OF `—� <br /> _ MA�TECA�VOCI~' <br /> WASTE HALMER'S SOURCE CERTIFICATION <br /> 1. PRODUCER OF LI UID WASTE <br /> NAME PHONE Zes —T�/ <br /> PICK-CTP ADDRE5S r.. <br /> Number iP r,_ c ,,,., ._. <br /> Street city State— <br /> zip <br /> WASTE SOURCE.' DOMESTIC WASTEWATER ONLY f m(circle`on eptic Tank oXtable To et <br /> PICTS-LTP DATE2,3^ <br /> l T��f -- QUANTTI'Y �. <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated._ <br /> Printed Nie of Owner,Occupant or Agent Sign Lire of Owne ccu ` t or Agent <br /> 2. HAULER <br /> NAME Roto Rooter ' <br /> BUSZTESS ADDRESS , r' <br /> Number Street City State 2ip <br /> I certify that the descnbed waste was haute/d by me to the disposal facility named below. <br /> Keceiving Station Permit No. �� / Vehicle l iemse No. aa <br /> Panted Name of Hauler �S :t�ureofH nler <br /> I <br /> 3, RECEIVING S'T'ATION <br /> NAME AND ADDRESS_ City of Manteca W CF 2450 West 'osemite Ave_ Manse <br /> ca,,CA 95337 <br /> i <br /> I certify that the hauler above delivered the desm-bed liquid waste to this disposal facility,amd that it s <br /> accepted/rejected(cimle one)material under the telms of the Receivuzg Station Permit. ; <br /> ' <br /> S' tare of�e Facility Operator <br /> DATE •. t �' TIME 1N � TIME QL7T_+ `NET QUANTTTY gals <br /> I <br /> Rev_021(19 orae assift mUfox ; <br /> 'd 6661 'ON Wd8l S l OZ Z ,a dy <br />