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. p► ack up <br /> ®erven� <br /> 5535039 �pIITM � � <br /> - <br /> Facility Telephone Number <br /> 0 HaulEer Tire Program ID / Site Suffix DATE <br /> HH /IN �� ®o <br /> 0 <br /> w <br /> III Whole Tire Count Weight in Lbs. —. <br /> O 2e �11 �) ® G I Volume Cubic Yds. Weight in Tons F f1 <br /> 0 <br /> Ono E. 11 Aadress Sarre as Hauler Initials <br /> i- =E n--^ I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE --'( /� <br /> 'i�tJlEr iB:��IJsiC:iC �'.�..<<i�'�r (N/A for //✓�y <br /> Whole Tires) <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> — — — INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> r <br />