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��61 '�N WdZS ll t [H '0Z 'Inr @WI j panian;� <br /> CITY OF AIANTFCA w CF <br /> �1-Qin <br /> WASTE HAULER'S SOURCE CERZTFICATION <br /> L PRODUCER QK LIOUD)WASTE pA <br /> NAME o �� PHONE <br /> PICK-UP'ADDRESS_ CIA <br /> Number Street City State Zip. <br /> WASTE SOURCE, DOMESTIC WASTEWATER ONLY from(circle oDie): Septic Tank Portable Toilet <br /> PICK-UP DATE_06, -0 7 TIlv4E 4LLd�) _ QUAN'TTiY� � Qals <br /> I certify that Ibis waste was delivered to the hauler named below for legal disposal a site indicated.. <br /> Panted Name Of Owner,Occupant or Avert Signature of owner,Occupant or Agent <br /> 2. <br /> I <br /> NAME Roto <br /> BUSINESS ADDRESS n tc�-J6� P, -4,) C4l zl , <br /> Number Street City Stare zip <br /> I certify that the descnW waste was hauled by me to the disposal facility named below. <br /> Receiving'Station Li <br /> tation Permit No-_ �—/ Vebiele cense No.71S 6 !qq <br /> -�--1 <br /> b1 Y�S 4 iA- <br /> Printed Name if Hauler It Sigustare of ffaul r <br /> 2 <br /> 3. RECEIVING STAT.I}ON <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. M <br /> aaToca,.CA 95337 ,I <br /> I certify that the hauler above delivered tha described liquid waste to this <br /> qui disposal facility,and that it was <br /> accepted/rejeeted(circle one)material wuder the Terms of the Receiving Station Permit. <br /> e or Was5pFacMty Operator <br /> DATE 46-09`—� Tn�IN 1�� °l TMM OUT NET QUANTIC <br /> Rcv.O7J09 office aui�diimns <br /> Z d HN 'ON Wd00 L10 '06 'lnr <br />