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i <br /> LOCATION TPID 1003974 a .;�, , PLEASE REMIT TO: <br /> 4001 N.Vasco Road ,_:as: :x:x: ea:taa P.O. Box 83328 <br /> Livermore, CA 94551 !V z. __ Portland, OR 97283 <br /> Livermore &Sacramento Area(925)447-0972 WASTE RECQVERY WEST. INC. 1 877 OLD TYRE <br /> Redding Area(530) 2751160 rr� [Hauler ❑Gen� �%ratot ❑End Use Facility <br /> Invoice Date � � ��I .'J Load Date l r Phone# ❑Pickup <br /> ❑Delivery <br /> Customer Name ����!C /y i`tC"' /C�l%'� <br /> Acct# _ <br /> y ' _ � � pSite Street Address— - (� iCity StateZt� <br /> 7 - <br /> I <br /> DRIVER I certify[hat undrr penalty ofperjury undgr the laws of the State of California that the information provided is true and correct.In addition,I am aware that <br /> Cal:i`cadon of this information may result In suspension,revocation,or denialof renewal bf the Waste Tire Hauler Registration pursuant to Public Resources <br /> ,p'+' /✓ Code section 42960 and may result in civil penalties up to$25,000 per day.per violatie¢t or administrative penalties up to$5,000 per violation per day as <br /> X,yr"' /�j�Z j/((� ( // !'(;'•. described in Public Resources Code section 42962. <br /> -- I HaulerEEemption Government FLEA <br /> E]Agriculture E]Common Carrier <br /> TRUCK# HAULER RLR LITH TRLR#'S DRIVER/HELPER MANIFEST# CASH/C[ARGE> <br /> LIC PLATE#, DECAL#y LIC STATE IMPORT ❑ LOCATION CUISTOMER�Pt #� ' TRIP LOG# <br /> EXPORT El <br /> LOADAMOUNTDescription LOAD TYPE C-'T-Y-P Rate Amount <br /> 1 �r <br /> Customer Signature �a,r` '` j Total Amount$ <br /> I certify that undeP pcii5lty of rjury under the laws of the State of California that the' rmation provided above is trot and correct Ih <br /> addition,I am aware that falsification ofthis information may result in civil penalties up to 25,000 per day,per violation or administrative *`e,� ,q <br /> penalties up to$5,000 per violation per day as described in Public Resources Code sect c n 42962. <br /> INVOICE C �.,3 i 6 <br /> I <br /> i <br /> I <br /> I <br /> i <br /> 4 f <br /> I - I <br />