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S11Pick Up Delivery <br /> :2 S <br /> Tive Site Stiff IX Facility Telephone Number <br /> L!J i l_� ` '� ( �,-r� i 1 - .`-i <br /> DATE <br /> 7.: D-. 6 <br /> 1? HR <br /> ku Whole Tire count Weight it)Lbs. <br /> L] VOILIMS Cubic Yds. Weight in Tons <br /> Initials <br /> Wks <br /> (N/A logy I CERTIFY THAT UNDER PENALTY OF PERJURY OF TME <br /> -4 Whole Tires) LAWS OF THE STATE OF CALJF0RNLA TKA7 THE <br /> INFOMAATION PRDVIOED ABOVE IS TRUE AND--CT <br /> 55825 1 XPick Up El Delivery 0 2 0 0 ® � <br /> Hauler Tire Program ID Site Suffix Facility Telephone Number <br /> DATE �� , � �I-, I � !_!_1® <br /> - L�1 ldf�® ��© ® � ® � <br /> WhWo Count ❑WligM to Lim <br /> F <br /> Z, t4u <br /> Hui ti []'Address Sarre as Hauler <br /> THAT UNUM Pe"LTY Of PH UUW OF THE <br /> r <br /> alt <br /> 5582560 VICk UP' <br /> Hat*w Tkv ft*Vwp ID 8de Suffix Facirtty Telephone Number <br /> q. <br /> ------ ------ <br /> ... . ...... <br /> Addre"Swne ar.Raul Aaaw,15111`1111111-,�- <br />