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rH <br /> • • i • r • • ■77 6 -- A Pick Up Deliveryy } Facility Telephone Number <br /> re Program ID / Site Suffix <br /> DATE <br /> ww Whole Tire Count ❑Weight in Lbs. /A C <br /> te- , ', j Volume Cubic Yds. Weight in Tons 100 er / g,/ <br /> E Hauler Name <br /> LUF= ;q",,/1 6-zwP c,�,- gsz3 f <br /> �i <br /> `soler Telephone Numbn; a ■ f 1 Address Same as Hauler <br /> (H/A for I CERTIFY THAT UNDER PENALTY OF PERJURY THE iy <br /> F O Y Whole Tims) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> '7 INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> (o, <br /> A <br /> 1. <br /> Z s5L ; ��C�C✓ <br /> R"i C� <br /> S 3 7 �3<� <br /> �I r� LA 1 . <br /> Customer Signature: % ��� <br />