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IaLUi anima <br /> Z6c6 � N Wdti� �Ol SIOZ ��l '� 0 1 P d <br /> CITY OF MANTECA WOCF mom l GlU <br /> WASTE HAULER'S SOURCE CERIRICATION <br /> 1_ PRODUCER OF LIQUID�WAgTE H <br /> P <br /> PICK-UP ADDRESS / C <br /> Number Street City State zips <br /> WASTE SOURCE: DOMESTIC WASTEWATER ON-Ly ft3n(circle one); eptfe'Tank Portable Toilet j <br /> PICK-UP DATE ' CF_'/ T&M QUANTITY ?�2-- els <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated <br /> Printed Name of Owner,OeeAp9lnt or eut g <br /> of <br /> of Owner,Oce mor Agent <br /> 2. AUI.ER <br /> NAMLc Rotg Rooter <br /> BUSINESS ADDRESS <br /> Number Strwet City S zip <br /> I cerkfY that the descn-bed waste was filed by me to the disposal facility named below_ <br /> Roceiving Station Permit No. � Vehicle License No. 773 <br /> Printed Name of)Banter <br /> Signature of n4aler i <br /> 3. R4C GST TION <br /> NAME AND ADDRESS:. City of Manteca WQCF 2450 West Yosemite Ave. Man <br /> teca,CA 95337 � <br /> I certify that the hauler above delivered the descriZed liquid waste to ibis disposal facility,and that it was <br /> accepted/rejected(circle one)material under the terms of the Receiving Staijon Permit <br /> S- atvre of Waste Fa ty Operator <br /> DATE TIl�IE OUT <br /> � � NET QUANTITY -2, <br /> iRev.02/09 office assi=r fi;= <br /> I <br /> E 'd 06ti 'oN AM :01 SlH 'til ';D0 <br />