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. <br /> H <br /> 932 L A Pick Up ❑ Delivery <br /> auler Tire Program ID / Site Suffix Facility Telephone Number <br /> DATE a® 2[01 l e+ <br /> w Who [A <br /> le Tire Count Wei 9ht in Lbs. <br /> E _ � v�P.- <br /> �x <br /> Volume Cubic Yds. <br /> 0 Hauler Na e O Weight in Tons j <br /> 1 Il�a� tc—dyd <br /> c �ress Sag�e- as Hauler nicr u <br /> (N/A fOr CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> L Y <br /> WhoIb TIr98) LAW3 OF THE STATE OF CALIFORNIA THAT THE <br /> INFORAMTION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> VVI IGCIJ y <br /> �T <br /> Trailer Placement $ $ Cash $ <br /> Trailer Switch $ $ Check $ <br /> Trailer Removal $ $ Charge $ <br /> Total Due Total Received is <br /> Driver Customer <br /> Signature: Signature: <br />