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L ,,ATION TPID 1003974 ".�,■� PLEASE REMIT TO: <br /> 4554 S. El Dorado St. WNWbI1035 _ _00 ° _�19 <br /> P.O. Sox 83328 <br /> 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 [I Generator ❑End Use Facility <br /> Invoice Date Load Date �� �� Phone# El Pickup <br /> ❑Delivery <br /> Customer Name Acct# <br /> Site Street Address ; i City '� - - %'�' State Zip—_— <br /> DRIVER 1 certify that under penalty of perjury under the laws of the State of California that the information provided is true and correct.Lt addition,I ant <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$15.100 per day,per violation or administrative penalties up to$5,000 per <br /> X— —u—�__ violation per day as described in Public Resources Code section 42962. Hauler Exemption ❑Government ❑LEA <br /> ❑Agriculture E]Comrtton Carrier <br /> TRUCK# HAULER TRLH LGTH TRLR#'S DRIVER/HELPER MANIFEST# CASH/CHARGE <br /> LIC PLATE# DECAL# LIC STATE IMPORT ❑ LOCATION CUSTOMER TPID#: TRIP LOG# <br /> EXPORT ❑ <br /> LOAD AMOUNT DHSCTIptIOn LOAD TYPE Rate Amount <br /> QUANTITY C-T-Y-P <br /> Passenger Tires @ <br /> Passenger Tires on rim @ <br /> 1 Manifest Fee 1.50 1.50 <br /> /j, <br /> if j ti4 1 <br /> 1<'Itl j. <br /> Customer Signature Total Amount$ <br /> t certify that under penalty of perjury under the laws of the State of CaUfornia that the information provided above is true and cor- <br /> rect.In addition,I am aware that falsification or this information may result in civil penalties up to$25,000 per day,per violation or INVOICE C <br /> administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. 178843 <br />