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5 68677867 <br /> -® A 0 Pick Up Delivery n <br /> Hauler Tire ❑ ❑ ❑ <br /> Program ID / Site Suffix n �f Facility Telephone Number <br /> U) DATE MD ; al /1 f <br /> ILI I% Whole Tire Count Weight in Lbs. <br /> F7 1 �� I © ~ Volume Cubic Yds. 11 Weight in Tons INS ' <br /> E Hauler Nan: ss <br /> City, State and Zip <br /> Stamp or Label OK <br /> Hauler Telephone Number ® � Address Same as Hauler <br /> /l Initials"/� /a (/(,•� (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> I VV Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THEj� <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT / <br />