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�D '°N PH :6 L ll 'Ia0 "Ili paniaaa� <br /> i <br /> �o �<�a <br /> CTTY OF MANMACA MQCF <br /> WASTE HAULER'S SOURCE CERTIFICATIpN <br /> 1. PRObU F LI UID WASU pH <br /> NAME I f PHONE / <br /> PICK-U.p ADDRES 5 ,f <br /> Number Street City Sure Zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from,(circle one): Septic Tank Portable Toilet <br /> PICK-UP DATES �� TMM ` ` QUANTTIy � t�� <br /> I c that thisto was delivered to tho hauler named below for legal sal at the site indicated. <br /> Ail"_ p <br /> � ICL�W�A� I <br /> PAn'6d Name of er,Occupant or Agent Signature of Owner,Occupant or Agent i <br /> 2. HAULER i <br /> NAME Roto Rooter <br /> BUSINESS ADDRESS <br /> Number Street City State zip <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No.__� 2 — T Vehicle License N�Za�L9_�'2_. ' <br /> ?c Lot_,O� 4,J1 <br /> Printed Name 6f Hauler 4 Signature of <br /> e <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS: Ci of W <br /> City QCF 2450 West Yosemite Ave. Manbeca,.CA 95337 <br /> i <br /> I certify that tha%auler above delivered the desanbed liquid waste to this disposal ty,and that it was <br /> accepted/rejected(circle one)material under the terms of the Receiving Statio j <br /> Z111il, <br /> Signature of Waste Facility Operator <br /> DATE© / U �! 7Tn m IN '�U TTME OUT NET QUANTITY <br /> Rev.07J09 <br /> of assista fc= I <br /> ,I <br /> ti 'd IL68 'ON Wd : 6 LIE 'W100'100 <br />