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1 I ni - - <br /> i CERTIFY THAT UNDER PENAL YY OF PERJURY OF THE <br /> ,"A for _ F CALIFORNIA THA. THE <br /> 1r-cie Tires) LAWS OF THE STATE O s <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Pick Lip ` <br /> . � Facility �'elephone Number <br /> e f Ti ! Site T 1l <br /> ID a r „re Program D Eil <br /> w Whole Tire Count a Weight 7L F-j <br /> in Llys. <br /> in Tons <br /> Volume Cubic Yds. Weigh# 1 <br /> r^ 1 <br /> Q <br /> Initials <br /> (NIA for 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tiles} LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Facility Tire Program <br /> Comprehensive • Log Number Load Information <br /> � � r � 3 �� <br /> Pick Up Delivery <br /> CL <br /> Facility Telephone Number <br /> Hauler Tire Program I® i Site Suffix DATE <br /> i <br /> w Q Whole Tire Count Weight in Lbs. <br /> iJ a <br /> ® Volume Cubic Yds. Weight in Tons <br /> F <br /> C <br /> n r Ii <br /> 0 Q MEE I Initials <br /> I f 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> STAT <br /> 0 O 2. 0 1 PROV I ME AAND 0 <br />