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Abt <br /> T) 003974 , .�,A. PL P.O. ox 83328 tv. <br /> LOCATION . Box 83328 <br /> 4001 N. Vasco Road ��' �__Z: "ZZ Portland,�_� �_ — Portland, OR 97283 <br /> Livermore, CA 94551 1-877-OLD-TYRE <br /> Livermore &Sacrament>At a (925)447-0972 WASTE RECOVERY WEST. INC. <br /> Redding Area (530) 27 -11 i ❑Hauler []Generator DEndUseFacility ` 5�f /(j Pickup <br /> i t t/_ 0 > Phone # 7U <br /> Invoice Date l i Load Date ❑Delivery <br /> Acct#------------------------- <br /> Customer Name- <br /> Zi <br /> p__ S ? <br /> City ° <br /> -fit CV.IG'o'r State <br /> �..1 ----------- <br /> Site Street Address / <br /> 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 /> DRIVER aware that t lalsificat on of this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to <br /> e ] Public Resources Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 pei <br /> Il�i 1")_ 'I ..�l I Hauler Exemption ❑Gnvcuit re ❑Co <br /> ! Il violation ger day as described in Public Resources Code section 42962. ❑Agriculture LEA <br /> ❑Common C 'et <br /> X---------------- ------------ <br /> TRUCK TRL'�LGTH TRLR#'S <br /> DRIVER/HELPER MANIFEST# CASH/ RG <br /> PL—IC—PLTATE pQE�GA #, LI�` WE IMPORT ❑ LOCATION I�111111:8 TPIA.#• Ca; <br /> TRIP LOG# <br /> I O"- V ` �"j' EXPORT❑ LOAD TYPE ff I Il 11 Y)) <br /> Rate Amount <br /> LOAD AMOUNT Description C-T-Y-P <br /> NTITY <br /> Passenger Tires @ F ... <br /> Passenger Tires on rim @ <br /> 1.50 1.50 <br /> 1 Manifest Fee <br /> Total Amount$ <br /> Customer Signature r lT/ M <br /> I certify that under pen Itv of Xegw s,under th I tsss i f the state of Califon is civil hat the information <br /> up provided <br /> per day,is true and on- ^)j •'h r` <br /> pp fication of this information may res p n <br /> z�... rect.In addition,I am awatarltac tglsr INVOICE C <br /> administrative penalties up to$5,000 per siolation per day as described in Public Resources Code section 42962. <br /> to destination and as to each party al any time interested in all or any said properry,mat every survicc Nay—,••��� ��.•�•��••�••••– •_. .. .... . - <br /> lo be performed hereunder shall be subject to all the Bill of Lading terms contract carriage and is signed by authorized representatives of both parties to the con <br /> SHIPPER ALCO ERON & METAL CO. CARRIER 1 Jif <br /> I _ <br /> PER �.�l 1 1 ' PER <br /> DATE <br /> -11AZARDOUS MAI ERIALi k''I��UL SIf;NAtE HAiAnoOus MATf'nIALS A� fll�ERENCEb IN•t9CFP§I r .'(1^,. <br />