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LOCATION TPID 1003974 ,■.M,■. PLEASE REMIT TO: <br /> 4554 S. EI Dorado St. Nevada 019 =_ __ ____ *a-== P.O. Box 83328 <br /> Stockton, CA t�'a WM100035 a __ a a_ a_ <br /> 95206 __ _ 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 <br /> El Generator ❑End Use Facility <br /> Invoice DateLo ad Date Phone# ❑Delivery <br /> Customer Name � 'i Acct# <br /> ,. _ ------------------------ <br /> Site Street Address tJ/ < �j, t City State Zip____=___ <br /> DRIVER I certify that unlm <br /> er penalty of perjury under the laws of the State of California that the information provided is true and correct.In addition,I a <br /> aware that falsification of this information may result in suspension,revocation,cr dercal of renewal of the Waste Tire Hauler Registration pursuant to <br /> Public Rcsourc�s Code section 42960 and may result in civil penalties up to$25 000 per day,per violation or administrative penalties up to$5,000 per <br /> X -----_—_—__-----_ -_ violation per day as described in Public Resources Code section 42962. Hadcr Exemption E]E] <br /> E]LEA <br /> j ❑Agriculture ❑Common.Carrier <br /> TRUCK# HAULER TRLR LGTH TRLR#'S DRIVER/HELPER MANIFEST# CASH/CHARGE <br /> LIC PLATE,# DECAL# LIC STATE IMPORT ❑ LOCATION CUSTOMER TPID#: TRIP LOG# <br /> EXPORT ❑ <br /> LOAD AMOUNT DOSCfIptl0n LOAD TYPE Rate Amount <br /> QUANTITY C-T-Y-P <br /> Passenger Tires @ <br /> Passenger Tires on rim @ <br /> 1 Manifest Fee 1.50 1.50 <br /> Customer Signature Total Amount$ <br /> I certify that under penalty of perjury under the laws of the State o£.CaBfocrua that the information provided above is true and:or- <br /> 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 'a <br /> administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. INVOICE C J � i <br />