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�W '°N WdOE : I LIOZ '� 'ApA ;WIJ pania)a� <br /> 0.� <br /> CITY OF MAMCA wocF <br /> WASTE ULER'S SOURCE CERTIFICATION <br /> 1. XRODUCER_OF LTOUM WASTE pH <br /> PIcK-U-PADDRESS X 03 0 s_ I��.��f1�J h7o� <br /> Number Street City State zip <br /> WASTE SOURCE. DOMESTIC WASTEWATER ONLY from(circle one Septic Tank Portable Toilet <br /> FICK-up DATE 7 IjvIE QUAN'IT!Y 3 2 teals <br /> I certify that this wasu was deli eyed to the hauler n=ed below for legal at the site indicated <br /> Printed Name of Owner,Occupent or Agent S. of Owner, ccapant or Agent <br /> •I <br /> 2. HAULER <br /> TAME Ro to <br /> Busnvl=ssADnit2rss y � ; ✓ ,P� 14 <br /> Number Street City Zip <br /> I cerdfy that the described waste was hauled by me to the disposal facfty named below. <br /> Receiving-Statiau Permit No. Vehicle License No_?�3�<y u <br /> Printed Name of Hauler tare of Ranier <br /> 3- RF,C G 5TAMN <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 Nest Yosemite Ave_ Mante a,,CA 95337 <br /> I certify that theuler above delivered the described liquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material under the trams of the kw4iving Station Permit <br /> •i <br /> S' a of Waste Facility Operator <br /> DATE <br /> TIME IN ✓ • o M Tmm O•UT NT:,Z'QUANMY <br /> Rev.01109 office rias Lf" S <br /> S 'd LLSL 'ON ME : [ LlH � �pW <br />