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HH 'ON WdL� : Z LIH 'ti[ '2ny au it PaAl ;)a� <br /> � T64 <br /> CITY OF 1VIANTE <br /> SCA <br /> WASTE I3AUT.E 'S SOURCE CERTTFICATION <br /> 1. PRODUCER OF LIQUID WASTE PH <br /> NAMED T_ PHONE 207 9 !r <br /> { 441, <br /> ', <br /> PICK-UP ADDRESS ��'Z Number S I-� I 6'CF l4L,�CA- IT-Sp <br /> Street City State zip <br /> WASTE SOURCE; DOMESTIC WASTEWATER ONLY from(circle one): Septic Tank Portable Toilet <br /> PICK-UP DATE -7//o zu TIME Yietv QUAN-J= 2� gals <br /> I certify that this waste was delivered to the bauler named below for legalDture <br /> the site indicated. <br /> Printed Name of Owner,Occupant or Agent Owner,Occupant or Agent <br /> I <br /> 2- <br /> NAME Roto Rooter <br /> BUSINESS ADDREMS <br /> Nuxnber Street City State zip <br /> T certify that the desc�waste was hauled by me to the disposal facility named below. <br /> Receiving'Station Permit No. 1 I Vebiele License No. S jC'�q <br /> Printed Name 6f Hauler C Signature of n4u-ler <br /> 3. RECEIVIl�G MWUQN <br /> NAME AND ADDRESS: Ci of MW <br /> City anteca QCF 2450 West Yosemite Ave_ Manteca.,GA 95337 <br /> I certify that the hauler above delivered the descnlbed h d waste to this <br /> cNi disposal facility,and that it was <br /> a cceptedfrejected(circle one)material under the Mi. of the.Receiving Station Permit j <br /> S e of Waste Fatality Operator <br /> �f� �� v <br /> DATE TIME IN TIME OUT NET QUANTTIY <br /> zals <br /> Rev,02/09 office asst m funw ' <br /> I. y <br /> ti 'd LM 'ON Wdss : Z L106 '°nv <br />