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. - - - .- <br /> L901 '�N =VuN Ol tiIOZ � 'lc 'fin( ;-j! panic a� <br /> 016 <br /> 7512 6 2 Facility Telephone Number <br /> r Tire Program ID / Site Suffixv) <br /> r <br /> . DD aaa � D © D <br /> Hauler r,,arne L - <br /> ��� ` <br /> p <br /> �Pres <br /> �da �s Sarre as Hauler <br /> /niNals —I <br /> >E <br /> -hauler ie 2L X10 f12 L'iilher - 4N1A 1DY I CERTIFY THAT UNDER PENALTY OF PERAIRY OF THE <br /> O G � -c _ Whole Tires). IAS OF THE STATE OF CALIFORNUITHAT THE 1` <br /> c,,-c (p J INFOANl.TION VROYYIED ASO 16 TRUE ANO CORREc. <br /> Trailer Placement $ $- - - - Cash $ . <br /> Trailer Switch $ $ Check $ <br /> Trailer Removal $ $ Charge $ <br /> Total Due r Total Received $ <br /> Driver Customer <br /> Signature: �r � Signature: <br /> - . . <br /> Up <br /> Pick Dellve I i t — p� �1 <br /> :. 4820133 -- B 0 © ® 0 D <br /> 7. Facility Telephone Number <br /> 0 Hauler Tire Program ID ! Site Suff9x DATE <br /> a. U t!J too . <br /> a V hole Tire Count:El welighFm Lbs. � 1 <br /> Z IC-DI Z ' r :D Volume Publc Yds.:❑:Weightin;Tons: £;� S <br /> 0 � D `t � <br /> Hauler Name o � <br /> U Yb C— r a D Address Same as HaulerEDE P. <br /> � �9 <br /> Hauler Telephone Number (WArar ICERDFYTHAT wflERPENALTYOF PERJURY OF THE <br /> �,nom — S whoIO:Tires) <br /> LAWS OF THE STATE OF CALFORNUI THAT THE <br /> `\1 (fl [/ INFORf1ATION PROMOED ABOVEIS TRUE AND CORRECT. <br /> Trude Tres $ $ <br /> Mise_Tires $ <br /> Wheels $ $ Payment Information <br /> Trailer Placement $ $ cash $ <br /> Trailer Swftch $ $' Cly $ <br /> Trailer Removal $ $ Charge LEE]Total Due Z_ i Total Received <br /> giver 2J�"�• Customer <br /> Signature_ �� r Signature: <br /> 9'd 96ZO-t,££-60Z-L uvzjziv oinv ebb:06 tq �91nf <br />