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�+ . . <br /> 4893710 '- V Pick Up Delivery <br /> IF ❑ ❑ ❑ ❑ ❑ ❑ � <br /> ❑ o <br /> Hauler Tire Program ID / Site Suffix <br /> DATE Facility Telephone Number <br /> �® / � � t<� <br /> ❑ ®� 0 ❑ y cy 9 <br /> M � a /hole Tire Count El Weight in Lbs. ❑ ❑ ❑ ❑ <br /> o Volume Cubic Yds. Weight in Tons <br /> o r r p f_ <br /> -.aule. i+-ante r- r^�I•�"1 3��Gr-.S E . �1� l� <br /> a <br /> Nauier eepihone Mumber ■ 1 B C s�{ <br /> l—J �� I t !�a�'a4er �l <br /> t Iitials <br /> (N/A for I CERTIFY THAT UNDER PENALTY CALIFORNIANI PERJURY OF THE rf <br /> C Whole Tires) LAMS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />