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[ZSt 'IN Wdt� :e tiIQZ ll�'n %pan1aaa�' <br /> CM OFsoloMAN"�"FCA W CF <br /> C) <br /> WAS'T'E HAULEWS SOURCE CERTIFICATION <br /> 1. PRODUCER OF LI-OM WASTE PH--L7 . <br /> f`. I <br /> NAME� _�'- PHONE <br /> PICK-UP AD-MESS Ct ir� {`C� 1L J 3o <br /> Number St-eet City State z <br /> I <br /> WASTE SOURCE:/DOMESTIC WASTEWATER ONLY from(circle one): tic T F Portable Toilet <br /> PZCF-up DATE /b ' ` J'`� TIME / 3 0QUANTTI"I' _ 32L2 zaLs I <br /> i <br /> Z certify that this waste was delivered to the hauler named below for legal disposal,at the site indicated. <br /> Printed Name of Owner,Octupint or Agent i a iWei a Owner, ecupaut or t <br /> 2. HAULE <br /> N "' Rooter <br /> BUSINESS ADDRESS qg°2 a �, .. S' � ,,� ►� ! <br /> Number Street City State Zip <br /> I certify tbat the descn'bed waste wa(ss hauled by me to the disposal facility named below. <br /> Receiving Station.Permit No. / d. "—� Vehicle License No. �`y <br /> T3�n <br /> Printed Name of Hauler Sinatare of Hasler <br /> i <br /> 3. RECEI Mg S-TATION . <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,,CA 95337 � <br /> I certify that the hauler above delivered the desm-bed liquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material under the terms of the Receiving Station,Permit <br /> Signature of Waste FadUty Operator <br /> DATE TIl E INT]7,m OUT NET QUANTITY 3�_gals <br /> Rev.02104 office assLstmdf01= <br /> { <br /> ti 'd l lH '°N 'AON <br />