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FOP"—, LOCATIONTPID if 1 Is .us' PLEASE REMIT TO: 4554 S. El Dorado St. Nevada. 9= _'°: =_ _ P.O. Box 83328 Stockton,CA 95206 wa WM100035 - = _; _ = Portland, OR 97283 Stockton &Sacramento Area (209) 234-0700 WASTE RECOVERY WEST.INC. 1-877-OLD-TYRE Redding Area(530) 275-1160 [Hauler El Generator ❑End Use Facility ❑Pickup Invoice Date ! � - � - I x Load Date''? - - Phone# ❑Delivery Customer Name ��? I (� i+ ' t l/nw�r a j Acct#------t------------------- SiteStreet Address � t /i r"TF %,._ �., }t :/City r P -7e-r7 State r;�Zip— ✓� __ , , , _ I certify that under penalty of perjury under the laws of the State of California that the information provided is true and correct.In addition,I am DRIVER aware that falsification of this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to _ Public Resources Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per X -V., �) violation per day as described in Public Resources Code section 42962. Hauler Exemption [:]Government i)LEA 'L — ---' -]Agriculture [:]C,y.jilmon Carrier TRUCK# ;- HAULER TRLR LGTH TR LR#'S DRIVER/HELPER MANIFEST# ASH/CHARGE LIC PLATE#rr DECAL# LIC STATE IMPORT ❑ .LOCATION CUSTOMER TPID#: TRIP LOG# EXPORT ❑ LOAD AMOUNT tLOAD TYPE Rate Amount DBSCfIptlOn ,C-T-Y-P UANTITY Passenger Tires @ J o 0 iii - Passenger Tires on rim @ 1 -Manifest Fee 1.50 -1_50_-_- Customer Signature , � �� , ;'�sf Total Amount$ I certify that undo penalty of pp,ujury,under the laws of the State of Calil`orm'oat the information provided above is true and cor- rect.In addition,I am aware"Lttat falsification of this information mWr�givil penalties up to$25,000 per day,per violation or INVOICE C F 'V administrative penalties up to$5,000 per violation per day as descvibed in P Gc Resources Code section 42962. TPID 1003974 ,�,��'■, PLEASE REMIT TO: t Nevada 019 =_ __ P.O. Box 83328 - Wa WM100035 _ —_ �— _ Portland,OR 97283 to Area(209) 234-0700 WASTE RECOVERY WEST. INC. 1-877-OLD-TYRE 5-1160 ❑Hauler ❑Generator ❑End Use Facility — [Pickup Load Date f_-1 Cet � - Phone# Delivery -V f 1 i!�^r Acct#-----�---- V City 7, r k T4 .10 State`' zip- 42 I certify that under penalty of perjury under the laws of the State of California that the information provided is true and correct.In addition,I am aware that falsification of this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative pe"riCg up to$5,000 per violation per day as described in Public Resources Code section 42962. Hauler Exemption ❑Government LEA _ []Agriculture 0 Common Carrier .,HAULER TRLR LGTH TRLR#'S DRIVER/HELPER MANIFEST# CASH/CHARGE .ECAL# LIC STATE IMPORT ❑ LOCATION CUSTOMER TPID#: TRIP LOG# EXPORT ❑ Description LOAD TYPE Rate Amount C'-T-Y-P Sehger Tires @ =ehger Tires on rim @ est-Fee--- 1.50 __1_50- Total Amount$ ury under the Ines of the State bf California that the information provided above is true and cor w � 00fication of perviolatiotn pertormation ay s described in Public Rresult in civil esources sectito o 042962 ay,per violation or 'i 01 INVOICE C �.774 �... 5)