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�60Z 'IN WdCti l t0 til 'Qny II� l panianadj <br /> MT OF MAN1 E�(F :I <br /> WASTE <br /> HAULER'S SOCTRCE CERTTRTCATTON <br /> ]. P ODUCER OF LI UID WANJT pH <br /> NAME PHONE__ Ze2 9� <br /> PICK-UP ADDRESS /_Ei, �- /`(� �.�W D C A � c� <br /> Number Street city State zip <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from(,ia (ne); Septic Tank portable Toilet <br /> PICS-UP BATETIME QUANTri-Y `l <br /> I certify that this waste was delivered to the hauler named below far legal " Sal at the site ' dicated_ <br /> �rY l <br /> Printed Name of Owner,Occup or Agent of Owner,Occupant or Ageut <br /> 2. PULER j <br /> NAME It Doter <br /> BUSINESS ADDRESS �2- <br /> Number Street City State Zip <br /> I certify that the desvrb waste was hauled by we w the disposal facility named below. <br /> Receiving Station Permit No. �l-(9 Eat Vehicle License No_ ID S�Sq a 9 <br /> tib- J <br /> Printed Nmie of Hauler SignAtare of H4uler <br /> z <br /> 3- G STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite A.ve` Ivlauteo- •CA 95337 <br /> I Omt&Y that the hauler above delivered the described liquid waste to this ahty, <br /> and that it was <br /> accepted/rejected(circle one)material under the terms of the R=tatLou <br /> --------------------- <br /> 84PAture of Waste FacMty Operator <br /> DATE 71V IN I TZM OUTi�J�_NET QUANTHYL S <br /> Rah.0210p officoas5zs�nUfvnas <br /> Z a' L9tiO Ad SS Z L10 til '°ny <br />