Laserfiche WebLink
LUG <br /> PID <br /> 4554 S. El TNevada 19 ,■.�,.. PLEASE REMIT TO: <br /> 4554 S. El Dorado St. Nevada 019 _ P.O. Box 83328 <br /> Stockton, CA 95206 IVa WM100035 I azz.? =_9 __ <br /> - - Portland, OR 97283 <br /> Stockton &Sacramento Area(209) 234-0700 WASTE RECOVERY WEST.INC. 1-877-OLD-TYRE <br /> Redding Area (530) 275,;1160 Hauler El Generator Q End Use Facility i <br /> Invoice Date - J <br /> Load Date Phone#^ f �l,'1/ ❑Pickup <br /> ! 1' e...-- � �/� �/°`I',i•� ❑Delivery <br /> Customer Name - `;r' ✓ Acct# <br /> Site Street Address_ City 4 State zip- <br /> DRIVER <br /> i <br /> p---� — <br /> DR IVER I certify that urider 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$5,000 per <br /> X-- _ `�--_4._...�--' violation per day as described in Public Resources Code section 42962. Hauler Exemption ❑Government ❑LEA <br /> ❑Agriculture ❑Common Carrier <br /> TRUCK# ..HAULER,.' ' TRLR EGTA I �:�� TRLR#'S i;• DRIVER/HELPER MANIFEST# CASH/CHARGE I <br /> � � {- �. <br /> LIC PLATE#, �, DECAL# LIC STATE IMPORT <br /> ❑ LOCATION <br /> CUST OMERT PID#, TRIP LOG# <br /> i <br /> ' <br /> EXPORT ❑ <br /> LOAD AMOUNT LOAD TYPE ' <br /> QUANTITY Description C-T-Y-P Rate Amount <br /> Passenger Tires @ <br /> I <br /> Passenger Tires on rim @ <br /> 1 Manifest Fee 1.50 1.50 <br /> Ll 7r <br /> Customer Signature r 1, I- Total Amount$ <br /> r <br /> I certify that under penalty ofperjury under the laws of the St4e of California that the information provided above is true and cor- <br /> rect.In addition,I am aware chat falsification of this information may result in civil penalties up to$25,000 per day,per violation or <br /> administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. INVOICE C 209858 <br />