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SIU "N Nd9l :l [ LIOZ 'S 'daS ;Wi j pan1a3ad1 <br /> i <br /> CME OF MANTE <br /> , CA WOCF <br /> WASTE HAULER'S SOURCE CERTIFICATION <br /> I. PROMO1F Lioup'WAS pH <br /> PHONE <br /> PICK-UP ADDRESS_��,O 6 '', L <br /> ,WNumber Stmt CityState zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLX from(circle one): Septic Tank Portable Toilet <br /> PICK-UP DATE_ " !s —? TIlVIE 'k 61� QUAN i I'l y <br /> I certify that this ate waJ delivered to the hauler named below for legal disposal a the " e indicated. i <br /> Printed N2Ae o er,Occupant or Agent S ccupant or Agent <br /> i <br /> 2. HAU1XR <br /> NAME Rom Rooter <br /> BUSINESS ADDRESS <br /> Number Street City State zip <br /> I certify that the d= bcd waste was hauled by me to the disposal facility named blow. <br /> Receiving Station Permit No. Vehicle License No.-7 <br /> pl i <br /> Printed Name of Hauler S, o H4aler <br /> 3. RECEVING S SON <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave. Manteca,CA 95337 <br /> I comfy that the&aulea 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 S P <br /> e o1'Vqaste Facility Operator <br /> DATE TIME IN zS ff� TIME OUT NET QUANT IT <br /> —_"is <br /> Rte, <br /> 0210p offct ass=staar/fvrms <br /> - I <br /> 'd 1692 "N NdLZ : Z [ LIE 'S 'd@S <br />