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;yr <br /> amp <br /> Q <br /> 5582551 -- B Fick Up Delivery ', It .� ` <br /> J 1 <br /> Y Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> DATE r <br /> ODD D n i 90:1GJ <br /> U Whole Tire Count ❑ Weight in Lbs. <br /> CL <br /> .� F] Volume Cubic Yds. Weight in Tons <br /> f <br /> Initials <br /> I' JI (NIA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> ) LAWS OF THE STATE OF CALIFORNIA THAT THE Whole Tires E17007 <br /> INFORh1ATION PROVIDED A5O1'r 15 TRUE ANO CORREC' <br /> ✓ 1 , <br /> Address Address <br /> City, State, Zip City, State, Zip <br /> Site Phone Interval Net 30/C.O.D./Cash/Check Drivers Truck/Name <br /> Customer PO <br /> Date.,,' <br /> Waste CA Manifest # Quantity Units Price Amount <br /> PRODUCT Code Gal <br /> Non-RCRA Hazardous Waste Liquid (Used Oil) <br /> 221 � Gal <br /> 223 Gal <br /> Non-RCRA Hazardous Waste Liquid (Oil &Water) Ze 133 <br /> . SRA Hazardous d Automotive Antifreeze) Drum(s) <br /> Non Waste Liquid (Use <br /> R� prum(s) <br /> Non-RCRA Hazardous Waste Solids Contaminated <br /> Contaminated with Used Oil <br /> „� <br /> Non-RCRA Hazardous Waste Solids Con DUO <br />