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HH 'IN MOS : I 2 10 2 '9l 'Ups 9WI J pane aaa�., <br /> I' CITY OF MANTEC,A.WOCF <br /> r <br /> OV TE <br /> HAULER SO 'LCE CERTIFICATTO <br /> 1. prRODMER OF LIQUID WAS Z2 f j <br /> II <br /> NAV Z30 P�6 e,(L5 PHONE <br /> PICK-,I ADDRESS 1 4 30 5 �{`CL� 0G( <br /> Number Street City State Zip <br /> I <br /> WASTIR SOURCE: DOMESTIC/WASTEWATER ONLY from(circle one): Septic Tank Portable Toilet <br /> PICk- DATE_ —/ S'/ / Tn. QUANTA Y <br /> I c t this waste was delivered to the baulcr named below for legal disposal at the site indicated <br /> ]Printed) ame of Owner,Occapan r Agent S*aature f ,Occupattt or Agent <br /> 2. sAvr.F <br /> NMVM Ii Roto Rooter <br /> BUS S ADDRESS <br /> Number Street City State zip <br /> I <br /> I certify t the descn'bed waste was hauled by me to the disposal:Facility named below_ <br /> Receiviu Station Permit No. Vehicle Li" se No. <br /> I'irnoiteda of Hauler Hig»e e o H- tiler <br /> II ; <br /> 3. EI c STA <br /> nQN <br /> NAME I' <br /> ADDRESS: City ofManteaa WQC,F 2450 West Yosemite Ave. Manteca,-CA 95337 <br /> I <br /> I certify t theauler above delivered tho described liquid waste to this disposal fsc d t e <br /> accepted! jetted(circle one)material under the terms of the Receiving Station P % r <br /> Signature of Waste Facility Operator � <br /> i <br /> DATE j 1 l TA1IE IN l l ITNIE OUT - �V NET QUANTrry 5J 0 <br /> i <br /> h <br /> I <br /> Rcv,OZ/09 o assistmdfom�s <br /> I' <br /> .I <br /> 'd 0096 "N Md : l 91H '9l 'ups <br />