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HE "N WdH :: 9 10 2 'S '2nd a'IIl Pan i aaad <br /> CITY OF CA IVQU sow <br /> WASTE HAULER'S SOURCE CERMCATION <br /> P <br /> 1- iAO�U� . Q�T1�u�WAM . <br /> PHONE <br /> PICK-UP ADDF.E35 2�03f <br /> Number Street City Stare Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY�fmm(deck one): Sep=ie Tank Portable Toilet <br /> Pidk-UP DATE r- TIME 1?�� QUAN= 3 <br /> I certify e5at d9s waste was delivered to ihe hauler named below for legal disposal at 8,e sm indicated. <br /> Prtatsd Name of 9 Oc ujmt or Amt Signature of Owner,Occupant or Agent <br /> NAME \\ <br /> r-1 <br /> BUSINESS ADDRESS <br /> Number Street City state zip <br /> I certify that the desm*cd waste was hauled by me w the disposal be iry named below. <br /> Receiving Station Permit No.'��-�� Vehicle License No. <br /> Printed Name of Haaber tnre of l41tter� <br /> 3. RECEI MG UATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yoscmite Avc. Mantas-CA 95337 <br /> I eery fy that the mer above dchvcred the desQ*ed hqmd waste to this disposal facility,and that it <br /> 2emptedhejected(circle ow)materiel under the terms of the Receiving SM on Perron. <br /> �igsta f Waste FacStity Orator <br /> DATE 15 %(P T1ME nv �( GT oar M90 Nor QUANrirY. 3 2 <br /> Rev.02M office . <br /> 'd KLS '°N WdSO : Z 9102 S '°ny <br />