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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 tml_ _3 = i_ - Portland, OR 97283 <br /> Stockton &Sacramento Area(209) 234-0700 WASTE RECOVERY WEST.INC. 1-877-OLD-TYRE <br /> Redding Area (5 30) 2T1 <br /> 7 160 El/ El End�/Use Facility Phone - / <br /> Invoice Date ` Load Date '� � st l 9Pickup ;. <br /> # _ +�' / <br /> � L�i Delivery/` <br /> Customer Name ' / X. Acct# <br /> Site Street Address_ f City State Zip <br /> DRIVER I certify that u idcr penalty of perjury under the laws of the State of California that the information provided is true and correct.In addition,I am <br /> r aware that fasTcation of this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to <br /> y�l.�, Public ResesCode section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per <br /> X__ --_ violation per day as described in Public Resources Code section 42962. Hauler Exemption ❑Government ❑LEA <br /> --------------- I ❑Agriculture ❑CommcgCarrier <br /> TRUCK# HAULER 1 TRLR LGTRI" �,^' TRLR#'SDRIVER/HELPED MANIFEST# CASW HARGE <br /> LIC PLATE It J//DECAL# LIC�STATE f• IMPORT ❑ - LOCATION ri7 CUSTOMEiR�J�'7PID#: TRIP LOG#EXPORT ❑ 1 f/�. <br /> LOAD AMOUNT Description LOAD TYPE Rate Amount <br /> QUANTITY C-T-Y-P <br /> Passenger Tires @ <br /> Passenger Tires on rim @ <br /> 1 Manifest Fee 1.50 1.50 <br /> Customer Signature Total Amount$ <br /> I certify that under penalty of perjur I(6c t of the S at o California that the information provided above is true and cor- <br /> ,.$d rect.In addition,I am aware that st tin of 's`inf rma;on may result in Boil penalties up to$25,000 per day,per violation or �pp�9 � <br /> . administrative penalties up to$5,060 per violation Derr day as <br /> 'described in Public Resources Code section 42962. GV ,(0�C lS G ,}ply <br /> I V ..6 <br />