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190� '0N �Atlrr Ol 7lOZ' 'lc 'fin( 7 A I paAiaa?y <br /> 9 4 4 5 02 -- A P1ck Up >Qeliv&,y - <br /> O. ❑ !moi <br /> •m <br /> v Facility Telephone Number <br /> a) Hauler Tire Program ID / Site Suffix DATE. �►%l / ®� / �� <br /> u�l [inn <br /> Lu WIL <br /> hole Tire count []Weight m Lbs. <br /> Votume'Cubic Yds;0 Weight in Tans <br /> E Hauler Name <br /> Q 7S- <br /> aider Teiep€Iorte Number ■OP �A,!Jdre Sarre as Fi uier 1 kers <br /> {NIA for 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> �Z J <br /> INFORMATION PRWADEDABOVEISTRUEANDCORREC.. <br /> ayment.Information <br /> Trailer-Placement $ $ '"Cash $ <br /> Trailer Switch $ Check $ <br /> Traer Removat $ $ Charge $ <br /> Tota! Due G Total Received $ <br /> Aver Customer <br /> ft��Ure: > � <br /> �9 Signature: <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 4820168 -- C �' _ 0 © � aa0 ®-� <br /> fcC� Dative <br /> P <br /> T. q. <br /> Hauler Tire Program ID ! Site Suffix <br /> ' Facility Telephone Number <br /> �Q`1rt/haFe=Tlre cgitnt ,❑'L^feigEttlrrtbs_ <br /> it r� <br /> ..., � i.� � .❑ Volurr►e OuSicYiis.a 11Yeig1jtin_ToJ-s- <br /> Hauer Name <br /> aoi rac res <br /> Hauler Telephone Number ■ Address Same as Hauler <br /> ��� ����� -. {ole�..- 1 CERTIFY OF T E STATE <br /> PENALTY OF PERJURY OF THE <br /> Whole Ticee) tAYI'S OF THE STATE Of CAL¢ORNW THATTHE <br /> INFORMATION PROVED ABOVE IS TRUE AND COPRE <br /> Truck Tires $ $ <br /> Mise.Tres $ $ <br /> Wheels $ $ Payment Information <br /> Trailer Placement $ $ Kash. $ <br /> Trailer Switch $ $-- Check $ <br /> Trailer Removal $ $ Charge $ <br /> Total Due otal Wed $ <br /> iveir Custarner <br /> mature: / Signature: <br /> Z-d 96Z£-V££-60Z-6 �Ilvjjv olfly e bV:o t7 l- l£Inf <br />