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LOCATION TPID 1003974 ,■.�,■, PLEASE REMIT TO: <br /> 4554 S. El Dorado St. Nevada 019 - -- ---- -- - P.O. Box 83328 <br /> Stockton, CA 95206 Wa WM100035 s_ Portland, OR 97283 <br /> Stockton &Sacramento Area (209) 234-0700 WASTE RECOVERY WEST.INC. 1-877-OLD-TYRE <br /> Redding Area(530) 2751-1160 Il Hauler El Generator 2-End Use Facility f7 <br /> Invoice Date '/ f Ltlad Date rj f Phone �i? .f�Y "�r-'/ E9-Pickup <br /> ❑Delivery <br /> Customer Name {'�'' Acct# <br /> Site Street Address City '=' Stater Zi <br /> //1 I certify that unlet penalty of perjury under the laws of the State of California that the information provided is true and correct.In addition,I am <br /> DRIVER ! ,•j aware that falsification of this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to <br /> v. <br /> 'V� Public Resources Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per <br /> x—_— ' _ violation per da},as described in Public Resources Code section 42962. Hauler Exemption ❑Government ❑LEA <br /> i ❑Agriculture []Common-G,arricr <br /> TRUCK# ;-'( HAULER,.//< TRLR LG)H /) TRLR#'S-1( DRIVER/HELPEpp�, MANIFEST# CASH/CHARGE <br /> IIS �l� �, il• if-�J'� r } <br /> ';..LICiPLATE#i, DECAL sp /,.: LIC STATE IMPORT ❑ LOCATION CUSTOMER TPID#: r TRIP LOG# <br /> n• ;r /'� iL_ /'S <br /> EXPORT El <br /> LOAD AMOUNT Description LOAD TYPE Rate Amount <br /> UNITY C-T-Y-P <br /> Passenger Tires @ <br /> Passenger Tires on rim Q <br /> 1 Manifest Fee 1.50 1.50 <br /> I <br /> r <br /> Customer Signature :,1� f %`i'-;.- ��-� -, Total Amount$ <br /> o.� I certify that under penalty ofperjury under the laws of the Staic of California that the information provided above is true and cor- <br /> rect.In addition,I am aware that falsification of ails information may result in civil penalties up to$25,000 per day,per violation or 209843 <br /> %� i <br /> administrative penalties up to$5,000 per violation per day as di cribed in Public Resources Code section 42962. INVOICE //��V 2 0 Vq0,�,8 4 3 <br />