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LOCATION TPIll Ir 4 PLEASE REMIT TO: <br /> 4001 N. Vasco Road =- =- == -= P.O. Box 83,328 <br /> Livermore, CA 94551 _ __= zz� :s; Z. Zz'„ <br /> 1925 j 447-0972 WASTE RECOVERY WEST. INC. Portland,1-877-OLD-TYRE <br /> TYRE 3 <br /> Fax (925) 456-7794 �7Hautcr ❑Generator <br /> ]End LJsc Facility tr-�- . <br /> Invoice Date /; Load Date Phone# i Pickup <br /> r riwn�I'eiivery <br /> Customer Name Acct#_______________ <br /> Site Street Addressi ir'\ <br /> ` City _. Stater ZiP------------- <br /> DRIVER I ccrtifi that under penalty of pery'ury under the laws of the State of Calilbrnia t hat the information provided is true and correct.In addition,I am aware that <br /> Ihlsificai inn r,t this inli,rmation may result in suspension,revocation,ordenial of renewal of the waste fire Hauler Registration pursuant to Pub Iia Resources <br /> ('011c section 4 29(i0and may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as <br /> X J,,c,iI,,d in I'ublic Resources Code section 42962. Hauler Exemption []Government []I.EA <br /> ❑Agriculture I�Conunoq.C^a <br /> TBllCK HA�ki1F�R TF?L H TRLR#'S'�� <br /> ,8I,V y DRIVER/HELPER MANIFEST# GASH/CHARGE <br /> LICPLATF= DECAL ' LIC STATE IMPORT ❑ LOCATION CUSTOMER TPID#: TRIP LOG x <br /> EXPORT I %J i-�` e <br /> 1;ATl AMnUr'r <br /> mrl;r Description LOAD TYPE C-T-Y•P Rate Amount <br /> i- <br /> Customer Signator.,, Total Amount$ <br /> �� I certili that under•cnalis:of Inrrjws•under the 6nvs of the titatc of C:alitbrnia that i he iulurntat ion Provided above is true and correct.In e7\ addition,I am aaardthat ialsitication of this intiarmarion n,av result in civil penalties up to$25,000 perday,perviolation or administrative <br /> `..:v penalties up to$5,0)00 per violation pct dams described in Public Resources C de section 42962. INVOICE <br /> w 1\/OICC C <br />