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HH 'IN Wdlti :Z L [0l 'til 'Any ;Wit pania3ad; <br /> �QMX OF M&Nnr W CF <br /> WASTE HACULER's SOURCE cER=i TION <br /> 1. <br /> PRODILQXR OF LLQ UID W TE <br /> NAME �7 PHONE <br /> PICK-UP ADDRESS--- � -0 5 C) �j o�(I ck A-L, Lc,"P, r-4, <br /> Number Street City State P <br /> 'WASTE SOURCE: DOMESTIC WASTEWATER ONL jY um(circle one): Septic Tank Portable Toilet <br /> Pick-up DATE MM L*40 <br /> QUAN'ITIY .� <br /> I certify that this waste was delivered to the hauler named below for legZiM�e <br /> at the site indicated <br /> i <br /> Printed Name of pruner,Occupant or Agent of Owner,Occupant or Agent <br /> 2. HAULER <br /> NAME R <br /> BUSINESS ADDRESS <br /> Number Stmct City Stare <br /> zip <br /> I certify that the described waste was hauled by me to the disposal facility named below- <br /> Receiv Station Permit No.- M-1), 17 0 Vehicle License No. �©�Li� <br /> Prpated Name o Hamer Signature ofloulex <br /> 3- STATYO <br /> NAME.AND ADDRESS- City of Mmteca WQCF 2450 West Yosemite Ave. M <br /> tera,.CA 95337 <br /> I certify that th�uler above delivered.the desanW ' d waste to this <br /> acc re ecte�d � disposal facility,and that it was <br /> eP� ] (circle oae)material under the terms of the Recemug Static of P <br /> i <br /> Sia of W Fa tg Operator <br /> DA'F TIME IN -- T <br /> —2Q0ANTIrY <br /> Rev-02/09 office atdSM=/fomes <br /> 'I <br /> d L8ti8 '�N WdSS : Z LIH 'til ny <br />