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Q 3837941 -- Pick Up ❑ Delivery <br /> Hauler Tire Program ID I Site Suffix Facility Telephone Number <br /> � DATE �® >' a® ,✓ <br /> (17 <br /> noo-as ® ao ® a <br /> Lu Whole Tire Count Weight In Lbs. <br /> F- <br /> 0 d 6 1 S ElVolume Cubic Yds.11 Weight in Tons <br /> E hauler Name <br /> Hauler Telephone Number � ■ � �} F^�Iclu$:.a. Same as.Hauler <br /> i / (Nle for I CERTIFY THAT UNDER PENALTY NI PERJURY E THE FT <br /> l_J1 YYh016 Tlroi) uYYS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> 5--.V C-.� r- 9 01 <br /> EIP <br /> � <br /> q z oz�o, <br /> A. <br /> T1s -f Y-) <br /> __j <br /> � 1 l <br /> Customer Signature: <br />