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amm <br /> ..I <br /> 339 <br /> 810 7 -- B Pick Up Deliveryr�l <br /> ® 0 ["Hauler.Tire Program ID / Site Suffixelephone Number <br /> DATE <br /> w -Whole Tire Count E]Weight In Lbs. <br /> Q ( 11 Volume Cubic YdCL , <br /> s. Weight in Tons Name/Addre!& C <br /> o Hauler Name City, State ara���� t,- .�W�► <br /> 3 <br /> uter It'll,: '.:. <br /> �jHauler Telephone Number ■ I Address Same as Hauler Initials <br /> E (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> 4""1O — Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE CORRECT. <br /> O o INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> •• Number <br /> Site Suffix <br /> 75 • • • •• <br /> -- Pick Up..,. Delivery I nn—a <br /> 3397760 A ® ® L <br /> Facility Telephone Number <br /> HaulerTire,Program ID / Site Suffix DATE `a,�./ © / 6 <br /> Lbs.in ht . <br /> Whole Tire Count Wel 9 <br /> Volume Cubic,Yds.a Weight in Tons �L�� (�57. <br /> Oity,State <br /> t <br /> "Hauler Name a lO� �.au"t-.¢,( lM�r j <br /> ... f.,(i iress Same as Hauler Initials <br />` v,460ir Telephone Number ■ <br /> CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> lilt <br /> (N/A for LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> 27 <br /> Whole Tires) INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> b � <br /> 00 <br /> til <br /> t <br /> f: <br /> ICA, <br /> r4 NJ <br /> r <br /> C. <br /> C-j <br /> l <br />