Laserfiche WebLink
LOCATION TPID 10' 4 .ES'.' PLEASE REMIT TO: <br /> 4001 N. Vasco Road '15:xx P.O. Boa 83328 <br /> Livermore,CA 94551 `_r ZZ, I, " '"15 Portland,OR 97283 <br /> Livermore &Sacramento Area (925)447-0972 WASTE RECOVERY WEST. INC. 1-877-OLD-TYRE <br /> Redding Area (530) 275-1160 ❑Hauler El Generator <br /> ❑End Use Facilin, <br /> Invoice Date Load Date Phone # Pickup <br /> ❑Delivery <br /> Customer Name Acct# _ <br /> Site Street Address City — State `j Zip_ ---------- <br /> DRIVER <br /> ___yDRIVER 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 <br /> aware that falsification of this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to <br /> Public Resources Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per <br /> X - _____________________ violation per day as described in Public Resources Code section 42962. Hauler Exemption []Government []LEA <br /> [-]Agricultare []C:ommon Carrier <br /> TRUCK# HAULER TRLRLGTH TRLR#'S DRIVER/HELPER MANIFEST# CASH/CHARGE <br /> LIC PLATE# DECAL# LIC STATE IMPORT ❑ LOCATION CUSTOMER TPID#: TRIP LOG# <br /> EXPORT <br /> LOAD AMOUNT Description LOAD TYPE <br /> QUANTITY ption C-T-Y-P Rate Amount <br /> Passenger Tires @ <br /> Passenger Tires on rim @ <br /> 1 Manifest Fee 1.50 1.50 <br /> Customer Signature -,---�— - Total Amount$ <br /> br <br /> I certify that under penalty of perjury under the laws of the State of California that the information provided above is true and cm- <br /> >: s rect.In addition,I am aware that falsification of this information may result in civil penalties up to$25,000 per day,per violation or <br /> administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. INVOICE C 1 4 2 U 7 2 <br />