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LOCATION TPID 1003974 ����,■� PLEASE REMIT TO: <br /> 4554 S. El Dorado St. Nevada 019 _— __ s: P.O. Box 83328 <br /> Stockton, CA 95206 Wa WML00035 e c- <br /> _ __ Portland, OR 97283 <br /> Stockton St Sacramento Area (209) 234-0700 WASTE RECOVERY WEST.INC. 1-877-OLD-TYRE <br /> Redding Area (530) 275-1160 ❑Hauler ❑Generator ❑End Use Facility <br /> Invoice Date Load Date Phone# ❑Pickup <br /> ❑Delivery <br /> Customer Name Acct#__________ <br /> Site Street Address City State Zip____ ___ <br /> 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 <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$5,000 per <br /> X _ --------- violation per day as described in Public Resources Code section 42962. Hauler Exemption ❑Government ❑LEA <br /> ❑Agriculture ❑Common Carrier <br /> TRUCK# HAULER TRLR LGTH TRLR#'S DRIVER/HELPER MANIFEST# CASH/CHARGE <br /> LIC PLATE# DECAL# LIC STATE IMPORT ❑ LOCATION CUSTOMER TPID#: TRIP LOG# <br /> - EXPORT ❑ <br /> LOAD AMOUNT Description LOAD TYPE Rate Amount <br /> QUANTITY C-T-Y-P <br /> Passenger Tires @ <br /> Passenger Tires on rim Q <br /> 1 Manifest Fee 1.50 1.50 <br /> Customer Signature Total Amount$ <br /> r. ,a I certify that under penalty of perjury under the laws of the State of California that the information provided above is true and cor- <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 - <br /> administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. INVOICE C <br />