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Program <br /> el�,ensive Trip Log Number Load Information Facility Tire <br /> _. Pick Up Delivery a ❑- ❑ <br /> .- 4789868 B 110 ® � <br /> a <br /> iv Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix DATE Ell- <br /> V) ® o � aoo <br /> c wa 1:1 Whole Tire Count ❑ Weight In Lbs. <br /> volume Cubic Yds. ❑ Weight in Tons W1 � s <br /> Stale <br /> o <br /> c"n Ll <br /> I' S �,iGrYt iV''' �ia9 <br /> a ` ❑ Address Same as l+der Initials <br /> Hauler Telephone plumber (N/A for ICERTIFY THAT UNDER PENALTY OFPERJURY OFTHE <br /> �� ---T.-r— ^Whole Tires) LAWS OFTHE STATE OF CALIFORNIA THAT THE — <br /> 5s�ll — INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />