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LAWS OF l HE 3 WFE OF ALIFOi{NIA CHAT i*' <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> sl• 4 • • • • • f • - f <br /> fb721 —" iia' t_ _ L �. <br /> I - <br /> - - <br /> 1' 'auier Tire Program ID / Site SUffix ��^ili�� Telephone Number <br /> l y � 0 <br /> 3 <br /> i W F] Whole Tire Count LJ Weight in Lbs. � <br /> g �" ❑ Volume Cubic Yds. Weight in Tons <br /> J . <br /> - ' <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECTE E E E . <br /> I <br /> I, Pick Up Delivery <br /> I Hal-lifer Fire Program !D ' Site Suffix Facility Telephone Number - <br /> ,� DATE F—11 <br /> i <br /> � L <br /> Ll <br /> � <br /> uj le(�l Whole Tire Count Weight in Lbs. <br /> �; „ ~ ❑ Volume Cubic Yds. ❑ Weight in Tons _ = <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> p' ROVIDI S ND CO <br />