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T <br /> (D <br /> CD N <br /> � N <br /> � O <br /> --I ."b Trip Log Number • • • - Program ID Site SuffixW <br /> -? 8986 C I Dick Up ❑ Delivery ® � M— <br /> lacility <br /> uler Tire Program ID I Site Suffix Telephone Number <br /> _ DATE <br /> ti G d Whole Tire Count Weight In Lbs. r n <br /> � / o <br /> El Volume Cubic Yds.El <br /> Weight in Tons <br /> i.r. .... . .. <br /> ev <br /> o ■ h1Ci,ii ;C•,f; .1'.',li�l`•'d.`.: 'i�jr:l:,� f Id <br /> f. ` 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Iv C C/� [iE �f _ /f/ (N IA for LA*8 OF THE 37117OALIFORHU THAT THE <br /> E OF <br /> �. G [ 1 �` Whole 71re•) <br /> ap INFORMATION PROVIDED ABOVE 19 U AND 0 T. <br /> Price Amount <br /> Passenger Tires $ �� d, $ Manifest# <br /> Light Truck Tires $ Trip Log..# <br /> $ <br /> Truck Tires $ License# <br /> $ <br /> Misc, Tires $ <br /> P <br /> Wheels $ $ <br /> Trailer Placement $ + Pr <br /> $ ,yk nt Information <br /> �;. <br /> Trailer Switch $ $ Cash $ <br /> ,_ <br /> Trailer Removal $ Check $ <br /> $ Charge $ <br /> Total Due Tota Received $ �' <br /> Driver <br /> Signatur Customer o <br /> Signature: <br /> rn <br />