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LOCATION TPID 1003974 . PLEASE REMIT TO: <br /> 4001 N.Vasco Road 3, -lea <br /> a:�; ta�L.lti P.O. Box 83328 <br /> Livermore,CA 94551 __ lei >; �� Portland,83 97203 <br /> (925)447-0972 WASTE RECOVERY WEST.INC. <br /> Fax(925)456-7794 1-877-OLD-TYRE <br /> lCl Hauler ❑Generator ❑End Use Facility <br /> Invoice DateOL - 20- <br /> A J". lP Load Datedt/ '1- 219 Phon� �/ �2 DeliveryEl <br /> Customer Name E A--,& /) Acct# <br /> Site Street Address .22,22) F 4U&) _ e Z h _ State _ZiP2 <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.1n 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$25,000 per day,per violation or administrative penalties up to$5,000 per <br /> _ violation per day as described in Public Resources Code section 42962. <br /> _ Hauler Exemption ❑Government [J LEA <br /> Agriculture []Common Carrier <br /> TRUCK/ HAULER ... RIVER/ ELP R <br /> T TR 7�LH I" D I N f MANIFEST N CAS /CRARG <br /> ( ' LIC PLATE/ bECAL# LIC STATE f? <br /> � IMPORT ❑ LOCATION CUSTOMER TPID#: TRIP LOG d <br /> 9 _NT EXPORT <br /> A ❑ <br /> LOAD AMOUNT <br /> QUANTITY Description ,EGAD TYPE <br /> T-Y-P Rate Amount <br /> [— <br /> r <br /> Customer Signature ,.� f.. 7 , -- -- <br /> r Amount$ r-- <br /> , @ I ccrtifp that ander a ty& ury under thelaws of the State of California that t information provided above is true and /� a� <br /> p cortect.ht addition,1 am aware t at falsification of this information may result in civil Penalties up to$25,000 per day,per violation INVOICE l.i/� l �1 <br /> or administrative penalties up to$5,000 per violation per day as described in Public Rrsources Code section 42-)62.432. <br /> M <br />