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Neva <br /> da 019 ®AAF®%®# PLEASE REMIT TO: <br /> 4554 S. El Dorado St. Wa WM100035! 2= ®a m P.O. Box 83328 <br /> Stockton, CA 95206 " '==v ;z. z- `--t`= Portland, OR 97283 <br /> Stockton &Sacramento Area(209) 234-0700 WASTE RECOVERY WEST.IIMC. Portia OLD-TYRE <br /> Redding Area (530)275-1160 ❑Hauler ❑Generator ❑End Use Facility <br /> Invoice Date Load Date Phone # DPickup <br /> El Delivery <br /> Customer Name Acct # <br /> Site Street Address City State ZipY <br /> 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 ant <br /> aware that falsification of this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant toPublic Resources Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per <br /> X___ ___ violation per day as described in Public Resources Code section 42962. <br /> Hauler Exemption oGovcrnment []LEA <br /> _ <br /> _ C]Agriculture C]Common Carrier <br /> TRUCK# HAULER TRLR:LO]H TRLR#'S DRIVER/HELPER MANIFEST# CASH/CHARGE <br /> LIC PLATE# DECAL ft LIC STATE IMPORT ❑ LOCATION CUSTOMER TPID#:-- TRIP LOG# <br /> _----_ EXPORT ❑ - <br /> LOAD AMOUNT LOAD TYPE <br /> QUANTITY Description _ CT Y P Rate Amount <br /> Passenger Tires @ <br /> Passenger Tires on rim @ <br /> Manifest Fee 1.50 1.50 <br /> Customer Signature Total Amount$ <br /> Ott I certify that under penalty ofperjury under the laws of the State of California that the information provided above is true and cor- <br /> rect.In addition,I am aware that falsification of this information may result in civil penalties up to$25,000�cr day,per violation or <br /> administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. INVOICE /'/a <br /> e <br />