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LOCATION TPID 1003974 PLEASE REMIT TO: 4554 S. El Dorado St. Nevada 019 _ ____ -MM-.%= P.O. Box 83328 Stockton, CA 95206 Wa WM100035 = = Portland,OR 97283 Stockton &Sacramento Area(209) 234-0700 WASTE RECOVERY WEST.INC. 1-877-OLD-TYRE Redding Area(530) 275-1160 ❑Hauler El-. ❑End Use Facility Invoice Date 1 Load Date j p$ Phone# %�7 r,' .'r'_j. r ❑-Pickup ❑Delivery Customer Name Acct Site Street Address rJ / 'f City State Zi DR IVtR 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 Resource's Code section 42960 and may result in civil penalties up to 525,000 per day,per violation or administrative penalties up to$5,000 per X_--_--- — violation per day as described in Public Resources Code section 42962. Hauler Exemption ❑Government ❑LEA ❑Agriculture [-]Common Carrier TRUCK# HAULERt,/• i TRLR-LGTW.' f a •TRLR#'S .rDIVER/HELPER MANIFEST# CASH/CHARGE i �i-v'��:l LIC PLATE 1f_ DECAL# LIC STATEIMPORT ❑ LOCATION CUSTOMER TPID#:_ . TRIP LOG# �'r,, i !r ,.' '�-(�' i�• EXPORT ❑ 41 J'' .' !/! LOAD AMOUNT Description LOAD TYPE Rate Amount QUANTITY C-T-Y-P Passenger Tires I Passenger Tires on rim 1 Manifest Fee 1.50 1.50 Customer Signature l•. ,_f ;:�' Total Amount$ I certify that under penalty ofperjury under the laws of the State of California that the information provided above is true and cor-rect.In addition,I ant 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 described in Public Resources Code section 42962. INVOICE C - _ .