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.� Program <br /> -4194046 -- A Pick Up ❑ Delivery <br /> -DATE Facility Telephone Number <br /> Hauler Tire Program ID I Site Suffix <br /> LAk'If RE `'VEST a �Whole Tire Count �Welght In Lbs. �K1� f�� W LS� co fly C � <br /> m <br /> I I r E]Volume Cubic Yds.❑Weight in Tons `/�- L L k n V <br /> E X33 ASC cn <br /> q 5 <br /> V Hat;a r T(,lenhone Nuill)hi Q ■ ( Addr 55 531110.i.4 Hau!er Initials <br /> 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE /` <br /> (N IA for LAWS OF THE STATE OF CALIFORNIA THAT THE t\ <br /> Yl T Who\l.T/IAr1B.) INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />