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11151 <br /> 3 940501) 0 • -- B - Pick Up Delivery © ® © �—p L <br /> Facility Telephone Number <br /> Haul Br Tire Program ID 1 Site Suffix <br /> DATE ���, a� <br /> Lu [] Whole Tire Count Weight In Lbs. <br /> 7 L? <br /> rE] Volume Cubic Yds.❑Weight in Tons L.) <br /> am <br /> & ,e as it, <br /> HEo .51 -? , g& <br /> —U I CERTIFY THAT UNDER PENALTY OF P NY OF THE <br /> (N/A for <br /> Wholes Tlr�) LAWS OF TNN STATE OF CALIFORNIA A7 THE <br /> iNFORMA'ncN PROVIDED ABOVE 13 TRUE AND COAprcT. <br />