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�W 'IN WdH :1 L 0 'E SpA auil paniaza� <br /> ".00. �I <br /> CITE'Off'MAN�,'ECA�'OC�' '! <br /> WASTE HAULER'S SOURCE CERTTFZCATION <br /> 1. PRODUCER OF LI UID WASTE PHL�L_1 <br /> PHONE_ <br /> PICK-up ADDRESS <br /> Number Street City State <br /> zip <br /> WASTE SOURCE; DOMESTIC WASTEWATER ONLY from(circle one); eptSc T Portable Toilet <br /> PIC$-UP DAVE S✓ /sZ -i i 'TIME <br /> I certify that this waste was delivered to the hauler named Belo,for legIStiMMof <br /> e mdicat�ecL <br /> Printed Name of Owner,Occup t or Agent Owner,Occupant or Agent <br /> Z. <br /> NAME Roto j <br /> BUSINESS ADDRESS <br /> Number Street City Staze zip <br /> I certify that the described waspe was hurled by me to the disposal faciRty named below. <br /> Receiving-Station Penmt No. - Vehicle License No. <br /> ?mated Name of Hauler tgnstore of Hauler <br /> r <br /> 3- G 5_TAnoN <br /> NAME AND ADDRESS: ofl�Ianteca W <br /> �Y QCF 2450 West Yosemite Ave. Msnteca,.CA 95337 <br /> I certify that'Plauler above delivered the descn-bed liquid waSte to this <br /> accepteftejected(circle 0m)material tinder the terms of the moo ' ,and that it�s <br /> Receiving Statiio <br /> i <br /> Waste Facility Operator <br /> DATE Z lo> MTE Ovr Nsr Qv � <br /> E Z <br /> Rev.OZ/09 offirr ass a�at/fvmts <br /> ,I <br /> d LLSL 'ON WdK :1 LIN ��W ~ <br />