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LOCATION T 003974 ,..�, PLEASE REMIT TO: <br /> 4554 S. EI Dorado St. a 019 MB--1 a: :::::, t::t�� P.O. Box 83328 <br /> Wa WM100035 :�, = Z.Stockton, CA 95206 Portland, OR 97283 <br /> Stockton &Sacramento Area (209) 234-0700 WASTE RECOVERY WEST. INC. 1-877-OLD-TYRE <br /> Redding Area (530) 275-1160 ❑Hauler ❑Generator ❑End Use Facility <br /> Invoice Date Load Date Phone# ❑Pickup <br /> "Delivery <br /> Customer Name Acct#-------_-----_--__---- <br /> Site Street Address City State Zip____________ <br /> DRIVER I certify that under penalty of perjury under the laws of the State of California that the information provided is true 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 pursuant to <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$5,000 per <br /> violation per day as described in Public Resources Code section 42962. Hauler Exemption ❑Government ❑LEA <br /> E]Agriculture ❑CommonCarnu <br /> TRUCK# HAULER TRLR LGTH TRLR#'S DRIVER/HELPER MANIFEST# CASH/CHARGE <br /> LIC PLATE# DECAL# LIC STATE IMPORT ❑ LOCATION CUSTOMER TPID#: TRIP LOG# <br /> EXPORT ❑ <br /> LOAD AMOUNT Description CO TD TYPE Rate Amount <br /> QUANTITY <br /> Passenger Tires @ <br /> Passenger Tires on rim @ <br /> 1 Manifest Fee 1.50 1.50 <br /> Customer Signature Total Amount$ <br /> I certify that under penalty of perjury under the laws of the State of California that the information provided above is true and cor- <br /> e - <br /> addition,I am aware that falsification of this information may result it:civil penalties up to$25,000 per day,per violation or /� <br /> administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. INVOICE C .. . <br /> LOCATION PLEASE REMIT 7.0.: <br /> TPID 1003974 ';".�,■. <br /> 4554 S. EI Dorado St. Nevada 0 __ _ __ Portland,OR 97283 <br /> Stockton, CA 95206 <br /> Wa WM100035 P.O. Box 83328 <br /> c_ �_ <br /> -y <br /> Stockton&Sacramento Area (209) 234-0700 WASTE'RECOVERY WEST.INC. I=877-OLD-TYRE <br /> Redding Area(53 )275 160 ❑ ❑End Use Facility <br /> 1 y1} @ ( Hauler e�ator tY rZ> ❑Pickup <br /> Invoice Date +f l� 1 _ Load;Date �' Phone# ' t o� , elivery <br /> Customer Name t 1J�(� 4 l Ti <br /> i_i `;,�. 0 r i Acct#__ �___�------- ,� <br /> Site Street AddressG. <br /> _ r ` <br /> { t� 1 .,�.-'( (� �� i► f^ MANIFEST# uC <br /> -�j( IYER ELPER <br /> t 1TRIP LOG# <br /> LOCATION CUSTMEA TPD# <br /> Q I certify that under penala of ❑ <br /> aware thar EXPORT ❑ - <br /> LOAD TYPE Rate Amount <br /> Desch tion L-./ c-T Y P <br /> -7 " <br /> per Tires @ <br /> Passenger Tires on rim @ <br /> 1.50 1*0 <br /> 1 Manifest Fee <br /> -4 - <br /> r^ _ <br /> Total Amount <br /> Customer Signature _ <br /> t,� a I cemfv that under penalty of perjury under the laws of the State of Califoiiiia that the,wtformation provided above is trot and tor- INVOICE C162-831 <br /> , - rest.In addition,I am aware that falsification of this information may result in civil penalties up to$25,000 per day,per violation or <br /> administrative penalties up ro$5,000 perviolation per day as described in Public Resources Code section 42962. <br />