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.9- 478921 A - - <br /> Pick Up ❑ Delivery �- <br /> U ❑ ❑ ❑ <br /> � Program Ip Site Hauler Tire Pr � � ❑ a � <br /> e Suffix ❑ EJ <br /> uDATE / ❑® / Facility Telephone Number <br /> M ❑ <br /> ❑❑ <br /> z - 0 a ® Whole Tire Count ❑ Weight in Lbs. ❑ ❑ (s �} <br /> .�. r ❑❑ <br /> o t daulei Same ❑ me Cubic Yds. El Weight in Tons Sas te,'s/��a�n Narne,;Address <br /> ❑ <br /> cit .Stat <br /> V F- y, eira1f�iIZVn,e!9 <br /> Maulet Telephone Nurnler <br /> a °'tas7tn or Label p" <br /> d ❑ Address Same as Hauler <br /> ( for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE lnitia/s <br /> Whole <br /> Tires) LAWS OF THE SigTE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.- k <br />