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tiDti "N WdH :6 LIE 11 '�)O awil pania);� <br /> M 400P <br /> CTFY OF M&M cA w CF <br /> WASTE I3AULER'S SOTIRCE CERTIFICATION <br /> I. ER—ODUCER QF LIQUID WASTE pH_C, j <br /> PHOMi <br /> PICK-UP ADDRESS /2 d - 5 j IA P6-0 Ll\, <br /> Pb <br /> Number <br /> Number Street City State zip <br /> WASTE SOURCE: DgOMESTIC WASTEWATER ONLY from(circle one): Septic Tank Portable Toilet <br /> PICK-UP DATE 0 Tr m �C�c. QUAN= <br /> I certify that this waste was delivered to the hauler named below for legal dr at the indicated. <br /> 1 <br /> Printed Nance of Owner,Occupant r AgentSi gnature of Owner,Occupant or Agent <br /> k° I <br /> 2. HAULM <br /> NAME Roto Rooter <br /> / - <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 Not �- ` � ._ Vehicle License No. <br /> Printed Nama-- <br /> auler Wgnatare of <br /> t72 <br /> 3. 499FAMG STATI <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 of the Receiving Station Permit <br /> Sig"ture of'Waste Fac- tp Operator <br /> DATE ��� Y l 7 TIME IN � �rTIME OUT NET QUANTITY <br /> Rev-02/09 office asistMWfM= <br /> Z 'd IL68 'ON WE : L I H I l '130 <br />