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/i4 � . <br /> ' SBtit '°N AVSl 8 E 0 S 'noN� aWII pania0a� <br /> 1-6 <br /> CITY OF ECA W CF <br /> - I <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> 1. PRQAUCER OF LIQUWASTE pH <br /> ID <br /> NAME <br /> PICK-UP ADDRESS / Q-40-30 Z& �5 �� <br /> i <br /> Number Street City State Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONI m(circle one): ptic I arr Portable Toilet ; <br /> ll <br /> PICK-UP DATr d�� TRAE QUANTITY Zajs 4 <br /> i <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated. <br /> Printed Name of Owner,Occppant or Agent S tore of , cc ant Agee <br /> . e <br /> 2. HAUI.,ER <br /> - i <br /> NAA Roto Rooter <br /> E'USINESS ADDRESS <br /> Number Street City State Zip i <br /> I <br /> I certify that the described waste was hauled by me to the disposal facility named below. a � <br /> Receiving Station Permit No. �� / Vehicle License No- <br /> Printed Name of Hauler Signature of Hauler <br /> f <br /> 3. RECEIVING STATION <br /> i <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,CA 95337 <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material under the terms okhe Receiving Station Permit. <br /> I <br /> L <br /> S e of Waste Facili perato <br /> DATE / IME IN ` TIME OUT 6/ T QVANTITY,5.0—ph <br /> i <br /> Rev.0210§-office assiMrit/forim <br /> b0/b0 39dd �DiO J 0101 9Z6SS9b60Z 9Z :80 ETOZ/50/TT <br />