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LOCATION TPID 1003974 <br /> 372 Florin Road PMB 276 11A,M'AN PLEASE REMIT TO: <br /> P.O. Box 83328 <br /> Sacramento,CA 95831-1407 �i' ►- ;rs = "__ _� Portland,OR 97203 <br /> Fax(916) 395-5572 WASTE RECOVERY WEST. INC. 1-877-OLD-TYRE <br /> (916) 395-5541 X.Hauler El Generator <br /> El End Use Facility <br /> Invoice Date �G P /�/� Delup <br /> ivery Load Date �/ � Phone# ❑Delivery <br /> Customer Name-0 U 4G/��h �r<f Acct# <br /> Site Street Address lf-14; )I-qale ll kr et, City _1 1 State / / Zip 's <br /> I <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$25,000 per day,per violation or administrative penalties up to$5,000 per <br /> violation per day as described in Public Resources Code section 42962. Hauler Exemption ❑Government ❑LEA <br /> ❑Agriculture ❑CommokCarrier <br /> TRUCK# Ir HAULER TRLR LGTH� TRLR#'S ,a�� f DRIVER/HELPER_ MANIFEST# CASH/,QFTARGk <br /> LIC PLATE# DECAL# LIC STATES IMPORT❑LJ LOCATION CUSTOMER TPID#: TRIPS LOG# <br /> EXPORT❑ <br /> LOAD AMOUNT Description LTYPE <br /> DUANTITY pion ADy-P Rate Amount <br /> I <br /> � I <br /> Customer Signature:- Total Amount$ 195- <br /> I <br /> r-I certify that under penalty of perjjury under the laws of the State of Cafifornia that the information provided above is true and ' <br /> correct.In addition,I am aware that falsification of this information may result in civil penalties up to$25,000 per day,per violation C (�Jj <br /> �� or administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. INVOICE <br />