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DATE Dec 7.2012 <br /> CUSTOMER Dave's Tire <br /> IFB ITEM CONTRACT NO. <br /> VEHICLE TYPE VAN LICENSENO BZ41804 STATE CA <br /> DIGITAL WEIGHT INDICATOR&PRINTER TICKET <br /> 26,680 -> Ibs.GROSS <br /> 13,900 -9> Ibs.TARE <br /> I <br /> 12,780 'Bl' Ibs.NET <br /> `,•vEIGHTMAS'T RS INITIALS/DATE J.C. , / DRIVER ON I OFF <br /> ,a i <br /> CUSTOMER/AGENT/DATE D.M. PASSENGER ON 1-1OFFE]�,j - � — 1 i.- <br /> vvcmHER: SNOW RAIN <br /> -'ENIARKS <br /> SHIPMENT RECEIPTIDELIVERY PASS (Prescribing Authonty: DCA Disposition Services Instruction 4160.94, Sec. 2, Ch. 6) <br /> 1 TO PURCHASER OR AGENT (Name of Carrier, if Applicable) 2. FROM: (Name and location of Activity and Installation from which property <br /> E is being removed) <br /> D,tiV'E'S TIR <br /> ' O. BOX 8 E DLA DISPOSITION SERVICES 700 E. ROTH RD. FRENCH <br /> FED BLUFF, CA 96080 CAMP. CA. 95231 <br /> INVITATION INUMBER 4. CONTRACT NUMBER <br /> IIEM 6. DESCRIPTION OF MATERIAL 7' UNIT 8. QUANTITY <br /> RELEASED <br /> SCRAP TIRES LB °'; <br /> � . . � <br /> Pick Up Delivery L51 i a r ❑61.5866 -- Qi Delive <br /> m Facility Telephone Number <br /> uDATE <br /> w Whole Tire Count�� ❑❑�' <br /> � 9 Hauler Tire Program ID ! Sita Suffix .• � .r ' �� �� �a <br /> " lei ht in Lbs. ., <br /> � <br /> 1 Volume Cubic Yds.❑Weight in Tons r"? <br /> Y` <br /> • � 1 � ,in,:yAi„�va:5 �-:?(Ji'r's `ftiwflN",• M/da/s <br /> t <br /> !A fOfI CERTIFY THAT UNDER F£NALTY OF PERJl112Y OF TNC LAWS OF THE STATE OF.lNCALJFp1NN TNAT THE� WhOIeTII'6a) FOFUIUTION PROVIDPD ABOVEISTRUEANDa�� 4 / 9� c 11. VEHICLE LICENSE N0. <br /> PARTIAL ZFINAL Q,, <br /> 2.RELEASED BY (Signature of PDO or Authorized Repfesentatice 13. TITLE OF AUTHORIZED DISPOSAL.REPR ESENTATIVE <br /> RELEASING PROPERTY <br /> iu,,lin Crouch (� /e- � _._.1- Property Disposal Specialist <br /> Ic:NA UItE 01=PURCH/j5t A,GENT \ IS. DATE PROPERTY IS RELEASED <br /> % 12/07/12 <br /> TO BE COMPLETED BY SECURITY PERSONNEL ONLY <br /> N\qE SI-IIPNILW LEAVES INSTALLATION17. SENTRY'S INITIALS <br /> DL11,DISPOSITION SERVICES FORM 1367,AUG 2004 <br />