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site Suffix <br /> a <br /> 3838289 A Pick Up Delivery <br /> Hauler Tire Program ID / Site Suffix <br /> Facility Telephone Number <br /> DATE o � o 0 o a <br /> w <br /> C w Whole Tire Count ❑Weight in Lbs. <br /> ■ a Facility i ;. <br /> m l t 0 volume Cubic Yds.[]Weight in Tons Namelk <br /> E <br /> Hauler Name city,StA7 OC) <br /> V a ■ 1 address Same as Hauler <br /> Hauler Telephone Number 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> (N/A for uwg OF 7HE STATE OF CALIFORNIA THAT THE <br /> ` L Whole Timm) NIFORNIATION PROVIDED=THAT <br /> TRUE AND CORRECT. <br /> i 1 <br /> 1 <br /> t <br /> oo it <br /> 3 <br /> 1��V <br /> I <br /> i <br /> I <br /> 's <br /> i <br /> �1 <br /> customer Signature: L_ <br />