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LOCATION TPID 1003974 I ,..�,■. IYLCAbt tttMl I 1 U: <br /> 4554 S.El Dorado St. Nevada 019 _ P.O. Box 83328 <br /> Stockton, CA 95206 Wa WM100035 c <br /> _> _ Portland,OR 97283 <br /> Stockton&Sacramento Area(209)234-0700 WASTE RECOVERY WEST.INC. 1-877-OLD-TYRE <br /> Redding Area(530)275- 160 Hauler Ge erator ❑End Use Facility <br /> j y �' '% 4/— QPickup <br /> Invoice Date �% Load Date - �- Phone'#j— E]Delivery <br /> Customer Name - �I I j E � Acct#-- <br /> Site Street Address A City State Zip <br /> 1 <br /> Ice 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 /> DRIVER aware that falsi8c tion of this information may result in suspension,revocation,or denial of renewal o£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$5,000 per <br /> X---- —r-,f. i`_ violation per day;s described in Public Resources Code section 42962. Hauler Exemption ❑Government E]LEA <br /> CAgriculture E]Common Carrier <br /> TRUCKN HAULER - TRLR LITH TRLR MS �SEHIHEk EAr.. MANIFEST N CASH/CHARGE <br /> LIC PLATE# DECAL# LIC STATE IMPORT ❑ LOCATION CUSTOMER TPID#: THIP LOG# <br /> EXPORT ❑ - <br /> LOAD AMOUNT DOSCI'I'tlon LOAD TYPE Rate Amount <br /> UANTITY p C-T=Y-P <br /> Passenger Tires @ <br /> Passenger Tires on rim @ <br /> 1 Manifest Fee 1.50 1.50 <br /> Customer Signature Total Amount$ <br /> I certify that underpenalty ofperjury under the laws of the Stat of California that the information provided above is true and cor- <br /> rect.In addition,I am aware that falsification of this informatio may result in civil penalties up to 525,000 per day,per violation orUs INVOICE C <br /> administrative penalties up to$5,000 per violation per day as d cribed in Public Resources Code section 42962. <br />