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3412 • <br /> 45a <br /> �� q Pick Up <br /> El Delivery <br /> Hauler Tire Program ID / Site. ❑ _ <br /> uffix ❑ ❑ �j <br /> D ❑ ❑ U � l <br /> ATE ❑ <br /> / cllity Tele <br /> � ❑� phone Number <br /> ❑❑ <br /> LU <br /> 11, u4Nhoie Tire count 000 <br /> >- Weight in Lbs>- ❑ <br /> E � � �-- ❑ <br /> at�ier olum acliit ❑ <br /> f/! <br /> Nam ❑ e Cubic Yds.E]Weight in Tons IA�4ame/A Su <br /> ity, lith <br /> Hauler'I"€:lelaiyone Number � <br /> am ll uler <br /> (N/A for 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Initials <br /> Whole Tires) LAWS OF THE STATE OFCALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> i <br /> Customer Signature: '' / ' --- <br />