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S9II 'IN WHLO : II LIH 'S 'add ;WIj pania�;� <br /> i <br /> !QM OF MANrECA w CF <br /> WASTE HAULER'S SOURCE CER JFICATrON i <br /> 1. KRODUCER OF LIQUID WASTE PH—Z, <br /> NAME PRONE <br /> PICK-UP ADDziESS / �0 ,P� y� <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(circle one). tie T Portable Toilet <br /> PICK-UP DATE__?�/ / % _Tag _ QUANTITY Z <br /> I certify that this waste was delivered to the bauiernamed below for legal disposal at the site indicated. <br /> Nrn,m1 <br /> Printed Name o Owner-,Oeen t or Agent SjgPdziure of Owner,Occupant or Agent i <br /> 2. HAULER <br /> NAME Roto RogtaI <br /> i <br /> suslrrEss AnnxEss /���� c�J �i^ S' � G <br /> Number Street City State Zip <br /> I certify that the desen`bed waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No.__ / Vehicle License No.,7,1—T5 <br /> Printed Name of Ranier lure of Hgnler <br /> e <br /> i <br /> 3. RECEDMG STATION . <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Ma1ftt0ca,•CA 95337 <br /> I certify that the hauler above delivered the dcsc ibed liquid waste to this disposal facility,and that it was i <br /> accepteWrejected(ci=te one)material under tate terms of the Receiving Station Permit <br /> &04fixe ofWaAe Facility Operator <br /> DATE 3 (3 I TITIE IN. �Q!! _TD IE OUT NET QUANTITY� U <br /> Rcv,02/09 office assistmadforms <br /> 1 ti 'd 9LEL 'ON AVtil : l l L I Oz 'S 'j CV _ <br />