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• • - • • •0`I 1 I-" • - •r.1- • • - • •1 e.1 I In I■ 1 <br /> EL 1 -- A Pick Up ❑ Delivery ® ® �— <br /> .m <br /> Hauler Tire Program ID / Site Suffix ® ©� Facility Telephone Number <br /> � DATE <br /> no n2oo ® aa <br /> W u ®Whole Tire Count []Weight!n Lbs. 1 <br /> EElVolume Cubic Yds.❑Weight in Tons " & — <br /> o fauler Name city, Q D earl^'�p <br /> a <br /> Hauler Telephone Number a l 0 Address Same ac Hamer /"ft/, <br /> (N/A'%, =THE <br /> THAT UNDER CALIFORNIA <br /> of PERJURY of THE <br /> r J( 7 <br /> Whole' r") uwa of THE STATE of CALoTHAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Z <br /> ST <br /> C Y <br /> Qt1�.l� 0 t e S C7 <br /> kO <br /> s c <br /> Customer Signature: `'"' <br />