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Pick Up Delivery �; ❑ LF-� ]I) <br /> LI) e❑] I <br /> 5686791 <br /> -- C Ll 0 <br /> � Facility Telephone Number <br /> C0 <br /> Hauler Tire Program ID / Site Suffix ❑ „ <br /> � DATE ❑❑ i� �� � _< ❑ `�i ..� _� 5 i � <br /> a <br /> oa o0 <br /> a w whole Tire Count Weight in Lbs. � .1 <br /> 'uUSltl�. <br /> G <br /> volume Cubic Yds. ❑ Weight in Tons <br /> 1 3 <br /> JE <br /> lauler Name���, _ , �� or Label DK <br /> ` Address Same as Hauler ,,,,ti�ls/"lauler telephone Number (N/A for (CERTIFY THAT UNDER PENALTY OF PERJURYE THE ex j <br /> /I,l Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE L <br /> � ' Nr ,� (06? <br /> L? INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT — <br />