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a�� �a�A„�� r , 3 161 �1—Do <br /> ®® p ® � � <br /> X865378 A <br /> Facility Telephone Number <br /> 0 f Hauler Tire Program ID / Site Suffix DATE' O �' <br /> � I © o <br /> as <br /> © ao <br /> ao <br /> VWei ht in Lbs. <br /> � a Whole Tire Count 9 � I•�<! sirless <br /> to <br /> M Q (, ® 1 ❑Volume Cubic Yds. Weight in Tons ,"Faln {q dl'ess v + <br /> L. I 1 ® 0 V q ) (,11, Ate fj55c,wvG � 'eJ <br /> 0 Hauler Mare <br /> O r a. r E] Address carne as Hauler Initials <br /> f - - I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> u-;cG�IE[ a�enilc;it� E�r;.11fl� 'u' .. (N/Afor <br /> Wh010"rll'85) LAW8 OFTHE STATE OF CALIFORNIA THAT THE <br /> T. <br /> - INFORMATION PROVIDED ABOVE IS TRUE AND CORREC <br /> i <br />