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. .. . . . reTin . <br /> _� Pick Up Delivery <br /> 4654375 C F ❑ <br /> ® Facility Telephone Number <br /> oa �Q � o <br /> Hauler Tire Program ID / Site Suffix DATE <br /> m <br /> w Whole Tire Count Weight in Lbs. <br /> ca a 'r( IZCS <br /> } GL X070 <br /> i O ~ Volume Cubic Yds. Weight in Tons <br /> 0 <br /> iaf.1I r rain <br /> e C <br /> '- F � <br /> z tc [-4AQCZr �;:i�J 2s 5fc�c�s - TOOO — <br /> U Q ■ J 1—„9 ;3ame -lS ,a'_IIc. Initials <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> (N/A for <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> n^C q IL IINFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> F�D <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suff ix <br /> 4 6 5 4 3 5 5 -- C ❑ Pick Up Delivery <br /> ❑ �� Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix <br /> DATE <br /> N © aava � o � aoo�❑ <br /> Lu Whole Tire Count Weight In Lbs.co <br /> —_ <br /> C} ( I ❑ Volume Cubic Yds. ❑ Weight in Tons <br /> - <br /> ONan e <br /> U Y a EEE ❑_ a 34G`CTC��:U G4� <br /> �'.=?cr�),�.�.,� ..],,,r,..� ■EE <br /> Initials <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> :2—cq 1 cl l, C Y1 Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> RECEIVE® <br /> AUG 16 2013 <br /> ENVIRONMENTAL HEALTH <br /> pFRAfiITIccow r:,:� <br />