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LOCATION TPID 10f ' ,�' , PLEASE REMIT TO: <br /> 4001 N. Vasco Road __:aa: a _a P.O. Box 83328 <br /> Livermore, CA 94551 is, " ' 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 ❑Generator ❑End Use Facility <br /> Invoice Date Load Date �' Phone# Pickup <br /> ❑Delivery <br /> Customer Name _ ' Acct # <br /> Site Street Address City State Zip__=__�__ <br /> DRIVER 1 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$5,000 per <br /> X —______________________— violation per day as described in Public Resources Code section 42962. Haulcr Exemption ❑Government ❑LEA <br /> ❑Agriculture ❑Common Carrier <br /> TRUCK# HAULER TRbR LGTH TRLR#'S DRIVER/HELPER MANIFEST# CASH/CHARGE <br /> LIC PLATE# DECAL# LIC STATE IMPORT ❑ LOCATION CUSTOMER TPID#: TRIP LOG# <br /> EXPORT❑ <br /> LOADAMOUNTDescription LOAD TYPEQUARite Amount <br /> C-T-Y-P <br /> Passenger Tires @ - <br /> Passenger Tires on rim @ <br /> 1 Manifest Fee 1.50 1.50 <br /> Customer Signature Total Amount'$ <br /> .1,! <br /> I certify that under penalty of perjury ttmder the laws of the State of CzliRxnia that the information provided above is true and cur <br /> rect.In addition,I am aware that PalsificiHon of this information may result in civil penalties up to$25,000 per day,per violation or /1 142638 <br /> ;b ,,.� <br /> administrative penalties up to$5,000 pb;violation per day as described in Public Resources Code section 42962. INVOICE C 1 4 2 <br />