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. . .- <br /> Pick U Delivery <br /> Y 89925 -- A P ❑ <br /> a Facility Telephone Number <br /> � a <br /> Hauler Tire Program ID / Site Suffix DATE <br /> Cr <br /> N ® oa <br /> aoa <br /> w �Whole Tire Count Weight In Lbs. <br /> c a � <br /> ® e_I <br /> [] Volume Cubic Yds. E] Weight in Tons €flame/Address�/3 5 S�Gcicfir�✓2 Sf <br /> Cp x yity,State and Zig <br /> E Hauler J�aine ? -�z, n±r I <br /> U)' <br /> 009DStamp ns• 1 _I <br /> � <br /> �,M a Ej Address Same as Hauler I„ I s <br /> U <br /> -lal.6iey" sele�'shone oo <br /> !umber (N/AfOr I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> �� ��• �/, ` INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />