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Nevada 019 %As WNSAIN PLEASE REMIT TO: 4554 S. EI Dorado St. Wa WM100035 �-=- °'== P.O. Box 83328 Stockton, CA 95206 _ Ex. `=' '° a arcPortland, OR 97283 Stockton &Sacramento Area(209) 234-0700 WASTE RECOVERY WEST.INC. 1-877-OLD-TYRE Redding Area (530) 275-1160 ❑Hauler El _ DEnd Use Facility Invoice Date d 7 Load Date � �% }-� Phone#% � �' ❑'Pickup j.j -7 ❑Delivery Customer Name- I"� �C.�/f/3 Acct Site Street Address Cit rr%fi y _'j State > Zip_ _-c 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 am .' aware that falsification of this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to _ Public Resour4s Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per X_ �'` '�—J violation per day as described in Public Resources Code section 42962. Hauler Exemption ❑Government ❑LEA ❑Agriculture ❑Common Carrier TRUCKV, HAULER.. TRLR LGTH;- TRLR#'S l ,r r t .DRIVER/HEL7.Ef� MANIFEST# CASHTCHARGE LIC PLATE# DECAL# i LIC STATE IMPORT ❑ LOCATION COTOMER TPIDC - TRIP LOG# i r;. Ja'1 EXPORT ❑ f! '.moi t:� i '''_j� LOAD AMOUNT LOAD TYPE QUANTITY Description C-T-Y-P Rate Amount Passenger Tires @ Passenger Tires on rim @ l 1 Manifest Fee 1.50 1.50 %�lrr Customer Signature Total Amount$ -- P�,o�. I certify that under penalty of perjury under the laws of the State of California that the information provided above is true and cor- rect.In addition,I am aware that falsification of this information 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 d scribed in Public Resources Code section 42962. INVOICE V