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DLl 'ON WdOti : ( LIH 'Sl 'D2a aWlj pania�adi <br /> X OF MANTEC,A,.W CF <br /> C� 16zi <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> d <br /> 1. PRUER QLIQUID pgR <br /> NAME <br /> Pxa g `� y <br /> _L 11 4 1 ADDRESS f ic) a -A Gt�f�✓ . <br /> I <br /> Number Street city Stare Zip <br /> WAS III SOURCE. DO STIC WASTEWATER.ONLY from(u�le one): Septic Tank Portable Tofler <br /> PIGS- DATE nam r QUANTITY <br /> I ceruf t. this waste was delivered to the bawler named below for legal disposal at the site indicated. <br /> *rIaV <br /> ted 6mi of ,Occupo Agent Signature of er,Occupant or Agelut <br /> I <br /> i <br /> NAME Rotokooter <br /> BUSINESS ADDRESS <br /> Nnmber Street City State Zip <br /> I certifyIII t the described waste seas hanled by me to the disposal facility named below <br /> Rei St uiou Permit No_ Yeb icle L icensc No_ <br /> Pnouted a of Hauler Signature of e# <br /> e <br /> I <br /> I <br /> 3- G STATION <br /> NAMM HAND ADDRESS: City ofMsatecaWQCE 2450 WestYosemibe Ave. Mameca,-CA 95337 <br /> .D I <br /> I certify I L the'�auler above delivered the d--bed liquid waste to this disposal facility,and that it was <br /> accepected(ei mle one)mats under the terms of the Receiving Station <br /> y I <br /> Signature of Waste Facmty Operator <br /> i <br /> -f <br /> RATE <br /> MM <br /> IN TIME OTrT I NET Q[TAN I1TY <br /> . I <br /> Rw_02/09 offida assi5t�t/fom<s <br /> Z 'd tiOti6 'ON WdO5 : l LIH 'Sl '��a <br />