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LOCATION TPID 10' 4 ..�' , PLEASE REMIT TO: <br /> 4001 N. Vasco Road P.O. Box 83325 <br /> Livermore, CA 94551 ' = � Portland,OR 97283 <br /> Livermore &Sacramento Area (925)447-0972 WASTE RECOVERY WEST INC. 1-877-OLD-TYRE <br /> Redding Area(530) 275-1160 F1 Hauler ` Generator ❑End Use Facility <br /> Invoice Date Load Date Phone# Ick <br /> 9-rGivery <br /> Customer Name Acct#__--_—__ <br /> Site Street Address <br /> city ��-� —State /' " ZiP-------- <br /> DRIVER I certify that under penalty of perjury under die 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$5,000 per <br /> X_____________________________ violation per day as described in Public Resources Code section 42962. Hauler Exemption ❑Government ❑LEA <br /> Agriculture []Common Carrier <br /> TRUCK# HAULER T9LR LGTH TRLR#'S DRIVER/HELPER MANIFEST# CASH/CHARGE <br /> LIC PLATE# DECAL# LIC STATE IMPORT LOCATION CUSTOMER TPID#: TRIP LOG# <br /> EXPORT I <br /> LOAD AMOUNT <br /> - <br /> QUANTITYLOAD <br /> _OyPP <br /> Description Rate Amount <br /> Passenger Tires @ <br /> Passenger Tires on rim @ <br /> 1 Manifest Fee 1.50 1.50 <br /> I <br /> Customer Signature Total Amount$ <br /> Opt <br /> I certify that under penalty of perjury under the laws of*he Sta*of Califorma tat t e infixmation provided above is true and cor- <br /> � t adm In addition,I am aware that falsification of this it ajaad a may result in civil Resources <br /> up to section <br /> 0 per day,perviolation or INVOICE C 2 <br /> administrative penalties up to$5,000 per violation per dfi"y as described in Public Resources Code section 42962. <br />