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6666 "N AVSO : OI 2 0Z '9 11 pan i aaa� „ <br /> CEly 4F M4NTE9A _ C•F � I <br /> . WASTE HAULER.°S SOURCE CER'I�'TC TION ' <br /> 1. PRODUCFR OF I UID WASTE pH <br /> NA . PRONE / a 1j <br /> PICK- ADDRESS 'I <br /> f rN I <br /> Number Street City JStith � <br /> WAST, SOURCE: DOMESTIC WASTEWA1 ER ONLY from(circle one): Septic Tank Portable Toilet <br /> PICK- DATE T1ME Q i QUANTITY <br /> I c this waste was delivered to the hauler named below for legal dispa�a1 <br /> 1 at the site iAdicated. <br /> Print "me of Owner,Occupant or Agent Sinattire of Owner,Occupaut or Ageot <br /> 'I <br /> 2. CJLE i <br /> NAME Roto R <br /> BUS S ADDRESS <br /> Pk <br /> Number Street City State zip <br /> I certify t the desodbed waste was hauled by me to the disposal facility named below. <br /> Rc:c Station Permit No. Vehicle License No. ;j <br /> •i <br /> Printed a of hauler Si"I tore of er <br /> 2 <br /> G STATIQ <br /> NAME ADDRESS: Ci of Manteca W <br /> City QCF 2450 West yosemiteAve. Manteca.-CA 95337 <br /> I certify rthe%auler above delivered the des=bed liquid waste to this e <br /> accept jetted(circle one)material under the terms off the Receiving Som �' t it was <br /> rvin�Sta n Permit. i <br /> S of este Facility Operator <br /> DATEI a TAS]N I I � TME OUT NE2'QUAN'TIT"Y� �` <br /> Rev-0210p vp <br /> 6 'd - 6EL6 "N WHSI : Ol 9 [0Z '9 gad <br />