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m <br /> �J 6 <br /> a. N <br /> n <br /> fV <br /> O <br /> fv <br /> W <br /> Cl) <br /> ti <br /> T <br /> CD 1 <br /> 0 <br /> . . c —[E <br /> �© <br /> a � D <br /> i� Pick Up �elivelry 0 <br /> 7 9 5 6 2 �� B Facility Telephone Number <br /> 0 <br /> )I a , Do <br /> Site Suffix DATEVR� ,/o � Hauler Tire Progrern 1D / DD .D <br /> y �y hole Tire Count l�Weight In Lbs. i rig/IC <br /> z ✓ n <br /> a <br /> M Volume Cubic Yds, ❑Weight in Tons £ /_ <br /> SP. <br /> to a,S� ,rC.6���- ,;V f7 <br /> CC, o <br /> N r <br /> ERSIFY THAT UNDS PENALT�` Q `/ Y OF PERJURY OF TRE <br /> r l 1 G <br /> U [, (N(p for LAWS OF THE STATE OF CALIPORNV\TRAT TRE <br /> WholeTras) <br /> / � /� INFOR,AATiON PROVIDED ABOVE 19 TRUE AND GORRECY. <br /> `(J <br /> Light Truck Tires $ $ License# I <br /> Truck Tires $ <br /> Misc.Tires $ $ <br /> $ Payment Information <br /> Wheelsj <br /> $ Cash $ <br /> v <br /> Trailer Placement $ $ Check $ I Z) <br /> Trailer Switch $ Charge $ rn <br /> Trailer Removal $ $ <br /> — -- $ <br /> Total Due Total�;� ��? • '. I. I <br /> �� Received o <br /> Customer <br /> Driver Signature: <br /> Sign <br />