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LOCATION TPT*3974 '• '•. PLEASE REMIT TO: <br /> 4554 S. EI Dorado St. Nevada 019 P.O. Box 83328 <br /> Wa WM100035 a <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 ❑Generator QEnd Use Facility <br /> Le <br /> Invoice Date Load Date '' ' Phone# Pickup . <br /> elivery, _•• <br /> CustomerNam e tR - -i Acct #-------------- ----- - <br /> f ,rte <br /> Site Street Address <br /> JL ct""• City . Stat-Zi <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 da as described to Public Resources Code section 42962. <br /> ,. ." --_____—____ P Y Hauler Exemption ❑Government ❑LEA <br /> — — <br /> [:]A <br /> ------------ <br /> g "rn on Carrier <br /> li TRUCK It HAULER TRLR L H TRLR#'S*"'" IV /HELPER MANIFEST# CASH/CHI�tGE <br /> .✓ :_+ J <br /> LIC PLATE# DECAL# LIC STA IMPORT ❑ LOCATION CUSTOMER TPID#: TRIP LOG# <br /> EXPORT ❑ .,.. 0 <br /> LOAD AMOUNT Description C TD YPP Rate Amount <br /> UANTITY <br /> Passenger Tires @ <br /> Passenger Tires on rim @ <br /> 1 Manifest Fee 1.50 1.50 <br /> I <br /> Customer Signature ` f Total Amoun � <br /> I certify that under penalty of perjury under the laws of the State of California that,the information provided above is true and cor- <br /> c rect.In addition,I am aware that falsification'ofthis information may result in civil.penalties up to$25,000 per day,per violation or pJg <br /> administrative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962. INVOICE q 12 p„^6y'A..,. <br /> I 3'?� <br />