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F 1 { <br /> � Y <br /> SI (j(th��s <br /> ' � •,, �, ,,, i CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> wh,,; F :._; LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> Pick Up Defivery <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> - • • . . • • • <br /> B F1 I <br /> P — Facility Telephone Winger <br /> W, Hauler Tire Program ID Site Suffix ��Tlv � I � � E <br /> �1 I r7 (� i <br /> Cz ! �. <br /> �� I I I L <br /> �— i 1 i I <br /> L+a UWhole Tire Count Weight in Lbs. <br /> M <br /> 2 Volume Cubic Yds. Weight in Tons <br /> 4 a <br /> r < H 1H" MHE <br /> tnlEi Ifs <br /> 3I CERTIFY TN.AT UNDER PENALTY OF PERJURY OF THE <br /> (N/A for <br /> F <br /> Whole Tirt,$� LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> -- - INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> _ • . s <br /> rE5 Pick UP i Delivery0E,, 16 A <br /> 1"acsli#;a Telephone Number <br /> gI-Jauler Tire Program ID / Site SUffixT F <br /> � � <br /> � Ju � � <br /> r Ltd Whole Tire COUnt Weight in Lbs. <br /> t U. <br /> s <br /> Volume Cubic Yds. Weight in Tans _ <br /> (NSA for I CERT IFY THAT UNDER rENALT1 OF PER,:'Jr,) OF H._ <br /> - ;� �_ OF THE STATE Or%ALIFORNIA THAT THE <br /> 1 I o <br /> N PROV ,g AND i �' T <br />