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PLEASE REMIT T <br /> 0IIu003S P.O. Box 83328 <br /> Portland, OR 9728 <br /> WASTE RECOVERY WEST.INC. 1-877-OI,D-TYRE <br /> 11.1111cf. Generator <br /> P Enti Use Facility _ <br /> ' -.--- Load Date' Phone# IJ Pickup <br /> ❑Delivery- <br /> Ls::„e N c - _------ ---- Acct# <br /> City State -- <br /> I cc,nk drat under penalty ofperjury under the laws of rhe State of Califbrnia that the information provided is true and corrcer,In addition,I am <br /> asvarc that falsification of this inibor atinn may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant t <br /> Public Rco-ourccs Code sccriun 42960 and may result in civil penalties tip to$25,000 per day,per violation or administrative penalties up to 55,000 <br /> si,knon per d.ry ss 1—ibed in Public Resource.,Code section 42962. <br /> - -- Haukr Ezcmp[ion Government FLEA <br /> []Agriculture ❑Common Can <br /> HAULER -TALRLGTH -TflLR#'S DRIVER/HELPER MANIFEST# CASHI&ARGe <br /> FLIC STATE IMPORT [, LOCATION CUSTOM ERTPID#: <br /> EXPORT ❑ � -'�.l r �., i! TRIP LOG# <br /> -" --s--tiLOAD TYPE <br /> _,- Description G T Y P Rate Amount <br /> hPassenger Tires @ <br /> I Passenger Tires on rim @ <br /> 1 Manifest Fee 1.50 1.50 <br /> Customer Signature Total Amount$ <br /> under peralry ofperjury under the laws of the State of California that the information provided above is true and cor- <br /> rc .. add:nan,I am aware char falsification of this information may result in civil penalties up to$25,000 per day,per violation or <br /> -®' -iantnrr c penalties up to 55,000 per violation per day as described in Public Resources Code section 42962. INVOICE <br /> C" 69 <br /> n, c•C❑ Htrvlrr � <br /> [?CATION TID 10o3974 PLEASE REMI1 <br /> Noada 019 1AIMAI, <br /> ��"a\�'�1100035zz.ca ="Mml P.O. Box 83328 <br /> Portland, OR 97 <br /> `z arca , 091 23.4-0700 WASTE RECOVERY WEST.INC. 1-877-OLD-TYB <br /> ❑Hauler ❑Generator ❑End Use Facility <br /> _ ce Cate Load Date I [J Pickup <br /> Phone# <br /> [:]Delivery <br /> C­S*=?e-Name - ACC[# <br /> -e Street aadress r' City y',..%�' State <br /> -_ = 1 certify char under penalty of perjury under the laws of the State of California that rhe information provided is[rue and correct.In addition,I am <br /> aware that falsification of this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuan <br /> Public Resources Code section 42960 and may result in civil penalties up to 525,000 per day,per violation or administrative penalties up to 55,00 <br /> violation per day u described in Public Resources Code secti6n'42962. <br /> -------- Hauler Exemption [-]Government []LEA <br /> -. Agriculture ❑Common Cr <br /> HAULER ,TALR LGTH "FALR.#'� D!J 11ERIHELPERMANIFEST# CASH/efTARGE <br /> . <br /> - -- =' CECAIi LIC STATE IMPUHI ❑ LOCATION 1 CUSTOMER TPID#: TRIP LOG# <br /> EXPORT ❑ I rl'! '" 1i 1 <br /> Description LOAD TYPE <br /> (C=T-Y-P Rate Amount <br /> Passenger Tires @ <br /> Passenger Tires on rim @ <br /> Manifest Fee <br /> $1NV01fVN= <br /> .50 1.50 <br /> Customer Signature _ <br /> unt$ <br /> rder p-salty of perjury under the laws of chc State ofClifornia that the information provided above is true and cor-I am awzre char falsification of this information may result in civil penalties up to$25,000 per day,per violation or <br /> srtmve penalties up to 55,000 per violation per day u described in Public Resources Code section 42962. le-1, If'3 ri <br />