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2 <br /> 7- 5768 6 8 0 7 �� Q �\ Pick Up ❑ Delivery LJ ❑ <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> cn DIDATE IE <br /> ; M <br /> 2 s <br /> @ w a Whole Tire Count Weight in Lbs <br /> a. ❑ <br /> r 7 y 3 ❑ volume Cubic Yds. Weight in Tons <br /> ❑ <br /> o Hauler Name <br /> U Q U Stamp or Label ©K <br /> Hauler///T---elep/hJo(n'e P'uniher ■ n Address Same as Hauler Initials ---I <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURYOF THE / <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE F�i <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />