Laserfiche WebLink
LOCATION TPID 1003974 ,�.®®�® PLEASE REMIT TO: <br /> 4554 S. EI Dorado St. NFvada 019 _ _ __ _ P.O. Box 83328 <br /> Wa WM100035 =_ == ==_ Portland,OR 97283 <br /> Stockton,CA 95206 = == =- -s <br /> Stockton &Sacramento Area (209)234-0700 WASTE RECOVERY(NEST.INC. 1-877-OLD-TYRE <br /> Redding Area (530) 275-1-160 <br /> ❑Hauler ❑Generator F-1 End Use Facility <br /> Invoice Date Y. 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 periury 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$5,000 per <br /> X--_-' violation per day as described in Public Resources Code section 42962. Hauler Exemption ❑Government ❑LEA <br /> ❑Agriculture E:)Common Carrier <br /> TRUCK# HAULER TRLR LGTH TRLR#B DRIVER/HELPER,'- MANIFEST# CASWCHARGE <br /> LIC PLATE# DECAL# LIC STATE IMPORT ❑ LOCATION CUSTOMER TPID#: TRIP LOG# <br /> - EXPORT ❑ - - j <br /> LOAD AMOUNT Description LOAD TYPE <br /> QUANTITY u_ C-T-Y-P Rate Amount <br /> Passenger Tires @ <br /> Passenger Tires on rim C <br /> 1 Manifest Fee 1.50 1.50 <br /> Customer Signature Total Amount$ <br /> 'd I certify that udder penalty ofperjury 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 55,000 per violation per day as described in Public Resources Code section 42962. INVOICE C <br />