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AA <br /> ry ti099 "N WdLti: l ti[OZ 9 [ ,[nrC;Jji j paniaa;� <br /> I <br /> CITY OF MANTECA WQCF <br /> WASTF, RkVLER S SOURCE CERTEFICATION <br /> PRODUCER O1F LI UW WASTE pH <br /> 4E )O1's e PHONE I <br /> 1 � a I <br /> -UP ADDRE /�C7 1 rlah � r<,0 ie <br /> Number Street City State Zip <br /> 31E SOURCE: DOMESTIC <br /> WASTEWATER ONLY from(ccirrccle ow): ep Tank portable Toilet <br /> -UP DATE .. /," QUANTITY ���Sals <br /> tify that this waste was delivered to the hauler named below for legal disposal hesireindicateti <br /> i <br /> I <br /> I <br /> ted Name of Owner,Occupant or Agent e <br /> 13AULER <br /> RM Rooter /! f <br /> JNESS ADDRESS <br /> Number Street City State zip <br /> tify that the described waste was hauled b me to the disposal facility named below- _ <br /> giving Station Permit No- O� Vehicle License NoK(o /X 12 <br /> I <br /> e��y lrU��e_- 4-.--- <br /> ted Name of Hauler Signature of Hauler <br /> • I <br /> RECEWINQ ST.A.T]4QN I <br /> SLE AND ADDRESS: City of Mauteca WQCF 2450 West Yosemite Ave_ Manteca,CA 95337 <br /> tify that the hauler above delivered the described liquid waste to this disposal facility,and that it was <br /> pted/rejected(circle one)material under the terms of4he Receiving Sta�Pit <br /> Signature of ante..Facility Operator <br /> i <br /> 'E C9�Y ZO { TIME IN' /3 3 G TJME OUT /Y: o NET QUANTITY X 38 z 9,16 <br /> I <br /> I <br /> )2/O�f office assiStanVforms <br /> 20/50 39Hd d3i00i'I oio�j 9Z6559b60Z T9:ZT PT0Z/9T/20 <br />