Laserfiche WebLink
"" PLEASE REMIT TO: <br /> LOCATION TP11� Gf3$3 �� <br /> - a +. P O. I�uh 83328 <br /> �'I;1 '� tt� Portiand <br /> 4401 N.VAsco KotOF,97283 <br /> Livermurc,CA#9.455,L t { l <br /> Livcrirlore,$r S;acrattlentq Area`(425) 4,47.004 � l „ '+ �N 17877-OLD-`L'1`RE <br /> R,cddi'iyg Area�(53U1 27 11 i) � �4�cr �' e irytorr� L7st Lctlity fn <br /> �f "t n M&up <br /> �' <br /> Invoice Date �„ i Load'Date Pi pn� LjDelivery , <br /> t ~ P, ... Acct – <br /> Customer Name <br /> hi,�jF` . <br /> I <br /> Site Street Address— 1 t� City State <br /> 1 <br /> leerlit}'thntunderpcnalryofperjuryundcrthelawsofthItStateofC'alifornigthattilt nforntationpiovided,strucand cnrrcct iniddmon Iamaware that <br /> Ex — <br /> falsifieation'afthiq information may result in suspension,rcvocation,or denial ofrenewal'ofthe SVaste Tire Hauler Registration pursuant to l t Clic ResourcesCode$tenon 42960 and may resultin civil penalnes-ip to 525,000 per day,per violaroir or'admmiscatn penalties up to S5,000per s,olatolt per dap— _ ___ described In Public Resourees Codc section 42962 1 Goventnicnt `—]LEA <br /> Hauler Esemp6on ❑, _, <br /> ___ �Agriiulturc Com qC Hcr <br /> TRUCK fi HAULER TRLR LGTH TRLR S DRIVE /HELPER MAMifEST CASHiC ARGE <br /> e TE IMPORT ❑ LOCATION CUSTOMER TPfDN; T9IP LOG# <br /> LIC PLATES O.CAL a LIC STA <br /> EXPORT L-i <br /> P r„ LOAD TYPE Rate Amount <br /> LUAU AMOUNT Description �' ���y .: ,7 ) C I`T"Y-PQUANTITY <br /> Total Amount$ L �"�)Z ( <br /> Customer Slgllature <br /> I certj,ljr atimd4F pen7l .tlf.¢Cluny 'E F��V�I ,',jk tj Cj{tE bP,Cdl tomta.�fat E jc lnformaoon provided above is true and couectlln /� /'+ <br /> C 13 <br /> n8, 941 b.S;2 QQp Gr da'r per;(t,olation or,drmiustran JNY)/�r116/E'. 116 <br />