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D.te �s <br /> No. <br /> 1Zn1!No.—Clerk_ FTYr 4RE3U _ <br /> 41 <br /> 71 <br /> 12 <br /> 14M15 <br /> ! 1A Your account stated to dole_If error is found return of once. <br /> Comprehensive Trip •• q • •.• • • Program <br /> re <br /> 3085981 �' A Pick Up Delivery I( I C? <br /> Hauler Tire Program ID I Site Suffix Facility Telephone Number <br /> w DATE <br /> a (Whole Tire Count Weight in Lbs. <br /> } Facility Business <br /> r- E]Volume Cubic Yds. g <br /> I C I Wei ht in Tons Name/Address <br /> o City, State and Zip <br /> Hauler Telephone Number <br /> 21/ ,max a I Stamp or Label OK q <br /> ■ lnitla ;1 <br /> Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> for Whole Tire Gaunt LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT, <br /> rogram ID Site Suffix, <br /> 3 0 8 5 9 81 -� Up L'=1 Delivery a U []PickME/717E-EE <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> V) <br /> DATE <br /> CL Whole Tire Count Weight in Lbs. a a o a o <br /> Facility Business <br /> `- 7 // Volume Cubic Yds. Wei ht in Tons <br /> I I� ice' C I g NameiAddress Z �r` <br /> o City, State and Zip <br /> Hagler Telephone Number <br /> Stamp or Label OK <br /> ■ '//�lnifials �� <br /> Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THy <br /> for Whole Tire Count LAWS OF THE STATE OF CALIFORNIA THAT THF ( 17 77 <br />