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tiI60 '°N Md :9 t0 l aPA ;UJII paniaaa�' <br /> IQ <br /> CITY OF MANTE <br /> CA WCF - <br /> WASTE H&UILER'S SOURCE CERT]RcAmN <br /> 1. PROP OF LI IIID WA, <br /> NAME Lr < /` PFiONEoC <br /> PICK-UF ADDRESS/,,-?D-F<7 S . �.�ir/ <br /> Number Street City "' Ststa Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(ale one): Septic Tack Portable Toflet <br /> PICS UP DATE-, Tl1V1El0 :i QUAN I7T�'✓2, <br /> I certify th-t this waste was delivmed to the hauler named below for legal at the site iudicated. <br /> Printed Name of Owner,()ceupaat a of Owner,Occupant or Agent <br /> 2. $AUE <br /> i <br /> NAME Roto Rooter <br /> i <br /> RUSMSS ADDRESS <br /> Number Street City State Zip <br /> I certify that the descalxd Waste was haWvd by me to the disposal fac�Mored below. <br /> Receiving Station Petmit No. Vehicle License Nom 7-.?6 �. <br /> c I <br /> Priated Name of HavUr tore of Haler <br /> 3. REC LIVING STA ON <br /> NAME AND ADDRESS- <br /> City ofManteca.WQCF 2450 West Yosemite Ave. Mauxeca,.CA 95337 <br /> I cry that the l=ler above delivered the dcscnbed ligmd waste to this disposal <br /> fan.-7ity,auci ttraz iz was <br /> accepted/ndmted(cizcie ane)m=erW under the teems of the Receiving Station Peg» <br /> Siignaiure of W2ste l;aclity Operator i <br /> DATE I f nTM IN ! I TIltit$OUT ��NET QUAN'!1TY �1 <br /> Rev.02/Op afffoeas /0,, <br /> z 'd LI IL 'ON &6� : 9 LlH a W <br />