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e� Pick Up Delivery ® F/I—9 ' <br /> 93702 <br /> V a <br /> 8 Facility Telephone Number <br /> d Hauler Tire Program ID / Site Suffix DATE <br /> N a o �® <br /> Lu Whole Tire Count Weight in Lbs. <br /> I c a h A <br /> �71/ Volume Cubic Yds. Weight in Tons <br /> i o :,ulerZoe 1 <br /> U <br /> i Q E] Ad iE'SS "fie S Ha�l8ner Initials <br /> G�aeuEeraeienho��ae !:ZE';'9 i`�er (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> /] ppp/� Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> l�. INFORM <br /> LTION PROVIDED ABOVE IS TRUE AND CORRECT. Fzz .— <br /> — lll... {-,� <br />