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LOCATION TPID 1003974 ,.r�,■' PLEASE REMIT TO: <br /> 4554 S. El Dorado St. Nevada 019 _ _ _ P.O. Box 83328 <br /> Wa WM100035 =_ = <br /> Stockton, CA 95206 Portland, OR 97283 <br /> = =- _ _ _- <br /> Stockton &Sacramento Area (209) 234-0700 WASTE RECOVERY WEST.INC. 1-877-OLD-TYRE <br /> ReddingArea (53'0)) 275-1160 QHauler ❑lGenerator-❑End <br /> -1Use Facility <br /> �+� -VP Load Date�Ll��Phone# �'ickup {` <br /> Invoice Date_ [�'�eliver¢y' <br /> Customer Name Aym 1 � 'nh�C tY�e� TL't s-=Acct#_____ <br /> Site Street Address � Y� &lt City { ��C')�Q _State Zip <br /> �c; <br /> DRIVER I certify,tHat under penalty of perjury under the laws of the State of California that the information provided is true and correct In addition,I am <br /> aware that falsification of this information may result in suspension,revocation,or denial of renewal of rhe Waste Tire Hauler Registration pursuant to <br /> � 'r/� <br /> Public Resources Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative penaltren up to$5,000 per <br /> y <br /> x_�/l i co o f�� violation per day as described in Public Resources Code section 42962. 1 lamer Exemption Ej Government ❑LEA <br /> 0Agrirulhirr ❑r'nmmnn rlrrir. <br /> GH U T L_f H T '�.,^ �jMML MANIFEST# CASHI ARG <br /> I TE Q~ <br /> DE� S`.(TE IMPORT([]Q` ,"(LLOOCCATION C TO ER 10 TRIP LOG# <br /> S� EXPORT ❑ <br /> LOAD AMOUNT AD TYPE <br /> I Try Description ju -Y-P Rate <br /> Passenger Tires <br /> Passenger Tires on rim @ es } ' -qs'S/ - Q <br /> 1 Manifest Fee F " g 0 1.50 1.50 <br /> Li%oaroio <br /> 14 SVp jy1titt J. E0 <br /> Customer Signatu Total Amount$ <br /> I certify that tit r t {criuty order aµ:v n e tate of Caliliirnia that rite wf xmninn ppruvided above is ituc and cor� <br /> rect.In addition, aware that falsi of thi.Information may result in evil penalties up to 525,000 per dao,per violation or INVOICE e 223462 <br /> administrative penalties up to$5,000 per vlolation per day as described in public fteaturce+CmIc motion 429e2 <br />