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LOCATION TP1D 74PLEASE REMIT TO: <br /> �- "vi—N�Vasco Road P.O. Box 83328 <br /> Livermore,CA 94551 Portland, OR 97283 <br /> Liveempre&•Sacramento Area (925);447-0972 WASTE RECOVERY WEST.INC. 1-877-OLD-TYRE <br /> Redding Area (530)2, 7t5 160 El` .,❑. Hauler Geaerat�r(Q�l- <br /> hd Use Facility <br /> Invoice Date <br /> - Lo <br /> adDate Phone r ❑Pickup <br /> Pvy <br /> Customer Acct# — -- <br /> --------- <br /> Site <br /> Site Street Address !f �l # y�1�i` �iSJL.j :� !dj l.' ) �,1'r, City i( ' rh f ;..-J a State ZIP <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 aware that <br /> falsification of thisinformation may result in suspension,revocation,or denial of renewal ofthe Waste Tire Hauler Registration pursuant to Public Resources <br /> Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative penalties tip to$5,000 per violation per day as <br /> X__-- described in Public Resources section 42962.„ - <br /> Hauler Exemption ❑Government ❑ <br /> LEA <br /> ❑Agriculture ❑Common Carrier <br /> TRUCK# HAULER TRLR LOTH TRLR#'S DRIVER/HELPER';: MANIFEST# CASH/CHARGE <br /> LIC PLATE# DECAL# LIC STATE IMPORT❑ LOCATION CUSTOMER TPIO#: TRIP L03# <br /> EXPORT❑ <br /> LOAD AMOUNTDBSCfIptlOn �'"- LOAD,TYPE Rate Amount <br /> QUANTITY fv ' C T-;N-P <br /> qu <br /> Customer Signature �� x yrs, Total Amount$ <br /> I certify that under penalty per ury under the laws of the State of California that the information provided above is true and correct.In <br /> Ai <br /> addition,I am aware that falsification of this information may resultin civil penalties up to$25,000 per day,per violation or administrative <br /> penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. INVOICE. C 132773 <br />