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Zti�8 '°N WdU :Z SIOZ 'Ll 'JCA ;inti Pani ;°;� <br /> MUF-MAMCAWOCF .r 00-7 <br /> WASTE HAULER'S,SOURCE CERTIFICATION <br /> �. > nuCol�- Ole wA <br /> pH �; Q <br /> NAW AC PHONE <br /> PICKUP ADDRESS _ z�r� Yl ;u-.1 - /..Yy C-- C <br /> Number Strut City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one): Septic Tm& Portftble Toilet <br /> PICK-UP DATE p. TIME � -- -2- QUANITIY- <br /> I cer6y that this waste w sd linea to the hmLkr named beJow for legal&Vosat at rl a site ia/dic ated <br /> t`ed Name S tr Owner,Oceupmt or Agent 'Signature of Owner,(?ec snt or Agent <br /> 2. <br /> NAME Rate R.aottar - <br /> BUSINESS ADDRESS <br /> Number Strout City - State Zip <br /> I C*Vify,that the described waste was healed by me to the disposal fwflity mated below. <br /> Receiving Station.Permit No. 9 Vehicle Lose&,No. 7 L}6� �^ <br /> PAUtW Nairne of Haaber Signature of HWUi / <br /> NAME AND ADDRESS: City of Mmtaca WQU 2450'Gest Yosemite Ave. Mant0M CA 95337 <br /> I,cw*that the hauler above delivered the d= bed liquid wssw to this disposal t$cility,and that it was <br /> aeeepted/rejectW(circle oat)material under the terms of the Receiving Stab Permit <br /> Signature of Waste Fadllty Opera or <br /> DATI; �� TIlNE <br /> IN I, f ._ ? TSMOU T1 ' 15PMNE T QUAr TnY? C2-' , <br /> e <br /> Rev.02M ofWe aZ fo= <br /> 'd BLLI '°N N60 :Z SIH 'Ll 'AN <br />