Laserfiche WebLink
LOCATION TPID 1003974 PLEASE REMIT TO: <br /> 4554 S. El Dorado St. Nevada 019 '•• ,•• P.O. Box 83328 <br /> Stockton, CA 95206 Wa WM100035' _ s's <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 [ ]-End Use Facility <br /> Invoice Date Load Date �f' Phone# % `)r Pickup <br /> r <br /> Customer Name f � ' I -+ Acct# ❑Delivery <br /> Site Street Address < City State Zip <br /> DRIVER: I certify that wider 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$2E,000 per day,per violation or administrative penalties up to$5,000 per <br /> X " '------ violation per Ay as described in Public Resources Code section 42962. xemption ❑Government ❑LEA <br /> Ha.ilcr E <br /> ❑Agriculture ❑Common Carrier <br /> TRUCK# HAULERTRR#'S DRIVER/HELPEqMANIFEST# CASH/Cf1ARGE <br /> LIC PLATE# DECAL.# , LIC STATE IMPORT ❑ LOCATION CU§TOMER TQID#: TRIP LOG# <br /> �,7 EXPORT ❑ I.. ,f !!f�1 <br /> LOAD AMOUNT LOAD TYPE <br /> QUANTITY <br /> Description C-T=Y-P Rate Amount <br /> I <br /> Passenger Tires <br /> Passenger Tires on rim @ <br /> 1 Manifest Fee I 1.50 1.50 <br /> i <br /> Customer Signature Total Amount$ - --� -- <br /> I certify that under penalty ofperjury under the laws of the Sate of California that the information provided above is true and,cor- <br /> 3 ° 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 P I <br /> administrative penalties up to$5,000 per violation per day asIdescribed in Pubfic Resources Code section 42962. INVOICE C 2 0 3 4 <br />