Laserfiche WebLink
LOCATION TPID 10 tIs .� ' PLEASE REMIT TO: <br /> 4001 N. Vasco Road BF W IP". t:s•r*a P.O. Box 53328 <br /> Livermore,CA 94551 '�` : Z.1 'ZZ'ZZ <br /> Portland,OR 97283 <br /> Livermore &Sacramento Area (925) 447-0972 WASTE RECOVERY-WEST.INC. 877-0LD-TYRE <br /> Redding Area (530),275,-11603 ' <br /> ❑Hauler ❑Generator ❑End Use Facility <br /> Invoice DateLoad Date Phone # O1'ickup <br /> ❑Delivery <br /> Customer Name <br /> Acct# <br /> Site Street Address City State {? zip /-- <br /> DRIVER <br /> ipj--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 <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$5,000 per <br /> X__-__________________________ violation per day as described in Public Resources Code section 42962. Hauler Exemption [jGovernment E]LEA <br /> ❑Agriculture ❑Common Carrier <br /> TRUCK# HAULER TRLR LGTH TRLR#'S DRIVER/HELPER MANIFEST# CASHICHARGE <br /> LIC PLATE# DECAL# LIC STATE IMPORT ❑ LOCATION CUSTOMER TPIOA TRIP LOG# <br /> EXPORT <br /> LOAD AMOUNT Description LOAD TYPE <br /> QUANTITY <br /> p C-T-Y-P Rate Amount <br /> Passenger Tires @ <br /> Passenger Tires on rim @ <br /> 1 Manifest Fee 1.50 1.50 <br /> Customer Signature ^'" Total Amount$ <br /> �. <br /> I certify that under penalty ot'perjury under the laws ot'the State of California that the information provided above is true and cor- <br /> rect.In addition,I am aware that hlsification 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 <br />