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Ot 0974 PLEASE REMIT TO: <br /> TPID l <br /> LOCATION ,. P.O. Box 83328 <br /> 4001 N�ca�,oad • <br /> $i�il IF 1,1113'a e�3 Portland OR 97283 <br /> :I :al ':i <br /> Livermore, CA 94551 1-877-OLD-TYRE <br /> Livermore &Sacramento Area(925) 447 0972 WASTE RECOVERY WEST.INC. <br /> R'eddingAreai(D30)j27S )16r [].('Tentgr d17�sePacilityr ?, � ���•_ 'I/ `:]Pickup <br /> r Vr <br /> Load Dat # 7 v <br /> Invoice Dat Y <br /> Phone "' � Hgeli er <br /> — <br /> tl <br /> Customer Name � �'. ! ~; <br /> til , �✓, f�" r i ,_� r .,City �.. r! ' :`J� State Zip_ <br /> Site Street Address <br /> I certify that under penalty bfpciJury under the laws ofthe state of Califonua that the information provided is true and correct.In addition,I am aware that <br /> DRIVER falsification ofthis information may ruult in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources <br /> 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 violation per day as <br /> Hauler Exemption Government [ILEA <br /> described in Public Resources Code section 42962. QAgriculture ❑Comm arrier <br /> fi <br /> TRUCK t HAULER TRLR LGTH TRLR#'S DRIVER/HELPER MANIFEST# CASHlC ARGE <br /> LIC PLATE# DECAL# LIC STATE IMPORT C] LOCATION CUSTOMER TPID#: TRIP LOG# <br /> - EXPORT❑ <br /> LOTYPE Rate Amount <br /> LOAD AMOUNT Description C T Y-P <br /> 1r5'1 U <br /> A I (.; <br /> Total Amount <br /> Customer Signature ,4t c_ar <br /> aj° '°z I ceriify that under g nalty of pperjury under the laws of the State of California that the information provided above is true and correct.In <br /> } add tion,I am aware that Nsification of this information may result in civil penalties up to$25,000 per day,per violation or administrative INVOICE <br /> N Y.C7IV <br /> penalties up to$5;000 per violation per day as described in Public Resources Code section 42962. <br /> �.. r.w�.w:.. ,..3..tom;:,.yr<r'rvot�- 'erre-D'0`OF rise?led oral or written contract promise}reLrre � n <br /> ui"a`".wW�wlwu a.. ay 4 y• P P y Y parties with respect to this freight,except to the extent of representation <br /> contract dg ' <br /> any <br /> nanding bet een tf)u <br /> w-r U understanding between the <br /> a yfT€e riarimeci <br /> et ui a or an said ro ert that ever se vice p g p which establishes lawful <br /> t`o"'Ee performed hereunder shelf be subject to all the Bill of Lading terms contract carriage and is signed by authorized representatives of toth parties to the contract. <br /> SHIPPER � p �,_.-_ - CARRIER L ( a - <br /> - - <br /> PER ------- --_ . .. <br /> PER <br /> DATE <br /> '"VARDOUS MATERIALS MARK TH'%' SIGNATE H ARDOUS MATERIALS AS REFERENCED IN 49CFR$172.202. -- <br /> Agent ust detach and retain this Shipping Order <br /> and must sign the Original Bill of Lading. <br />