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el cASE REMIT TO' rru) 1ooaa-4 ,■."IAN PLEASE REMIT TO: _J�>Tl�n Ne,,h 011) _ _ P.O.Box 83328 �C�11uu0M. '5 - =-' == Portland, OR 97283 OU' _3+-0-00 WASTERECOVERYWEST.INC. 1-877-OLD-TYRE l l 00 Hauler ❑Generator D End Use Facility C11'ickup e _ _ Load Date 7 Phone# Delivery ! Acct#--------- Sc c ass - City " State Zip —--- I cerntv that under penalty'of perjury under the laws of the State of California that the information provided is true and correct.In addirion,lam that falsifintion of flus information may result in suspension,revocation,or denial of rencwal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to SS,000 per —lanun per d.tv as described in Public Resources Code section 42962. Hauler Exemption Q Government ❑LEA ------ ❑Agriculture i_;Common Carncr' TRLfl LOTH TREfl#'S-- DRIVER/HELPER, MANIFEST# CASH/CHARGE - -_-_ ,LIC STATE IMPORT ❑ LOCATION CUSTOMERTPID#: TRIP LOG# EXPORT ❑ �f. ,I _..•�. tLOAD TYPE Rate Amount Description c-"T-Y-P Passenger Tires C Passenger Tires on rim @ ? Manifest Fee 1.50 1.50 ;a S;G'.er 5�ynzture - - Total Amount$ -Q, - -¢, ;• riu under the Iaws of the Scof California that the information provided above is true and cor. ; a v t falsification of this mtb mauon may result to civil penalties up to 525,000 per day,per violation or yes_ ,p 35,000 per violation per day as described in Public Resources Code section 42962. INVOICE C {1CertnN PLEASE REMIT I PLEASE REMIT TO: a'1.;010 ,_ •_•�__ ,■,_ P.O. Bo:( 83328 :: Portland, OR 97283 WASTE RECOVERY WEST.INC. 1-877 OLD-TYRE Hauler Generator End Use Facility Pickup Load Date Phone# Deliver' Acct#_---- -= -- City State _ Zip— '-T— ---- --- - ------ .-- r:•.r. ecc i•17 i.nr.of perjury under the laws of the State oFCalifornia that the information provided is:rue and correct.Li addicon,I am ms information may result in suspension,revocation,or denial of renewal of th<R'astn Tire Hauler Revsv-ation pu,000tram m secrion 42960 and may result in ci,il penalties up to 525,000 per day,per violation or adminismdva penalties up to SE,000 _-_____-_-_-___ ....:;,�„pods.r 1—ribed in Public Resources Code section 42962. Hauler Exemption []Government `LF-4 --_ �:Sgriculturc _Comityem C TRLR LITH -TRLR#'S DRIVERIHEIPER- MANIFEST# CASHICHARGE UC STATE IMPORT ❑ LOCATION CUSTOMER TPID#: TRIP LOG# EXPORT ❑ " Description LOAD TYPE Rate Amount ts-- Passenger Tires @ Passenger Tires on rim @ lAarlifest Fee 1.50 1.50 Total Amount S JL `tc of Calitisnia that the information provided above is true and cur- 0;