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l'.O. Bos 83378 <br /> Portland,OR 9/28 <br /> 1110,0-4 '■.�'■. PLEASE REMIT TO:, <br /> P.O-Box 83328 <br /> Portland,OR 97283 <br /> WASTE RECOVERY WEST.INC. 1-877-OLD-TY-RE <br /> Hauler Generator End Use Facility <br /> Load Date Phone# Pickup <br /> - -- - ---- �-♦•Delis ery <br /> _ <br /> S­e'. w C. _ss City - r : - State Zip---` <br /> _ I:c:n that under penalnui perjury under the Invs of the Sutc of California that the informatlon provided is the and correct.In addition,I am <br /> - '� rc that ialsitiotion of this iniormazion may resuh in suspension,roocation,or-0enial of rcnnyal o(thc\Cu;c Tire Hauler Rc¢isrration pursuant:<, <br /> Public Resources Code section 42960 and may result in civil penalties up to S25,000 per day,per-lanon or administrative penalties upto 55,000 pe.- <br /> t ,- —liman per day as ciewnbed in Public Resources Cod,section 42962. Hation ❑Govcrnmcm LEA <br /> [].gnn� <br /> ........ <br /> -----------.......... uler Exemp4 Iture Common Carne-' <br /> _epi r -.A7LER iRLR LGTN ]JfLR,71'S' ORIVERIHELPER MANIFEST# CASHICHARGE <br /> Li <br /> UC STATE IMPORT ❑ LOCATION CUSTOMER TPI D#: TRIP LOG 3 <br /> EXPORT El <br /> °_s I Description LOAOTYPE Rate Amount <br /> C=T-Y-P <br /> Passenger Tires @ <br /> Passenger Tires on rim @ <br /> Manifest Fee 1.50 1.50 <br /> r S 3na%,e Total Amount S <br /> .. f qury under the laaa of the State r Cal(omnia that the mformatian provided above is true and ccr- <br /> I,at 6luncauon of,h.information v result in civil penalties up to$25,000 per day,per violation or <br /> t 55,000 per vsolanon per day as dcwrib d in Public Resources Code section 42962. INVOICE C <br /> i <br /> I hlty tun;•>-4 PLEASE REMIT TO: <br /> . . - ado Olo <br /> P.O. Box 83328 <br /> Scv <br /> \l 1000,5 -= =° '--'- ='- == Portland,OR 97283 <br /> 'Oil '?+ 0_00 WASTE RECOVERY WEST.INC. 1-877-OLD TYRE <br /> ' I a0H,nllcr ]Generator ❑End Use Facility <br /> C Pickup <br /> Load Date - Phone# Delivery ' <br /> Acct#------------------- <br /> e 2. __. . .ss_. City ^) - State ZIP <br /> I ccctin dvu under penahp of perjury under the laves of the State oFCalifornia that the information provided is true and correct.In addition,I am <br /> •' aaam that falsification of this information may result in suspension,revocation,or denial of renewal of the Wsste Tire Hauler Registration pursuant to <br /> Public Resources Code se van 42960 and may result in civil penalties up to 525,000 per day,per violation nr administrative penalties up to 55,000 p <br /> viohmon per day as described in Public Resources Code section 42962. Hauler Exemption ❑Government <br /> L1 LEA <br /> U <br /> ______ _ ❑Agriculmrc Common C"oe, <br /> HAULER TRLR LGTH TRLR-11'$ DRIVER/HELPER, MANIFEST# CASH/CHARGE L <br /> ❑ , LOCATION CUSTOMER TPID#: TRIP LOG# <br /> -- DECAL a LIC STATE IMPORT - - <br /> -- - e - EXPORT❑ <br /> LOAOTYPE Rate Amount <br /> Description C-T-Y-P <br /> Passenger Tires @ <br /> Passenger Tires on rim @ <br /> 1 Manifest Fee 1.50 1.50 <br /> I ' <br /> l Total Amount$ <br /> .:'corer Signature <br /> , - ±::: I - I <br /> _ _.. ♦:cr^der;r.-r.,.r:«pperlun under the laws of the State of California that the information provided above is true and eor- <br /> a•.r<ohm fds,finunn of the information may result in civil penalties up to 525,000 per day,per violation or INVOICE ettl .� cy <br /> .c penalucv up o,$5,000 per vsolatuan per day as desenbed in Public Resource Cotte section 42962. 1 L� <br /> v <br />