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I <br /> PLEASE REMIT TO: <br /> LOCATION TP, 103974 P.O. Box 83328 <br /> 4001 N. Vasco Road --: <br /> ;g; Portland,OR 97283 <br /> Livermore, CA 945511-8 77-OLD-TYRE <br /> Livermore &Sacramento Area(9 5) 47-0972 WASTE RECOVERY EST. INC. <br /> Redding Area (530) 275-1160 ❑Hauler ❑Generator End Use Facility Picicu <br /> Invoice Date ( � - Load Date Phone # E]Delivery <br /> (J i(J pJh� �., Acct#------------- <br /> Customer Name _ ,-----�''1) <br /> --- <br /> t� w,�4 r r i . ,r,�' state 1 zip—'�`�— --- <br /> Site Street Address City ,_{ <br /> I certifv 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 falsification of this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Reg stration 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$5,000 per <br /> �. __— ' t/'.1',� — violation per day as described in Public Resources Code section 42962. Hauler Exemption ❑Government iJ LSA <br /> X �•(j, ----�— --_—_--_ CAgricuiture ❑Comnic!pCarritr <br /> ++ TRUCK#4t 1 H��l1Ejjj TRQR PTH TRLR#' U DRIVER/HELPER MANIFEST# CASH/ ARGE <br /> 11 << (, LOCATION '�C#U$}O61jID#:,}) TRIP LOG# <br /> CPLAT # DF�AL# LIQ STfiE IMPORT ❑ ( l) {� rV <br /> G S EXPORT❑ <br /> LOAD AMOUNT Description CO T-YLADYPP ROl Amount <br /> QUANTITY <br /> Passenger Tires @ <br /> Passenger Tires on rim @ <br /> 1.50 1.50 <br /> 1 Manifest Fee <br /> It I <br /> �r <br /> - Total Amount$ <br /> Customer Signature <br /> °along 1 certify that undo penalty of petjury under the laws of the State of California that the information provided above is true and cor- <br /> rect.In addition,Nfn aware that;hlsification of this intixmation may result in civil penalties up to$25,000 per day,per violation or INVOICE C p <br /> administrative penalneruppto S5,000 per violation per day as described in Public Resources Code section 42962. <br /> entation or <br /> ---��_-j _--s to each <br /> - f all or an of said Property over all or any portion of said route alleged with es or asserted <br /> oot torthis freight,r.c alor written epi to thee,ext nt of anyi5wr tten contract whichreslahlr;! <br /> s mutually agreed as to each carries n Y <br /> to destination and as to each prtrty at any time interested in all or any said proPety,that every selwre parties P — <br /> to 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 <br /> SHIPPER ALCO IRON & METAL CO. PER <br /> ARRIER <br /> r <br /> PER <br /> / _,_—.—._—------'---- <br /> „�;;,,Rr,-,,1 r,r,„si EfnAl ti -Ma8K-4YlIf1_"X�Ula1N51iiNi+i i,I IAZARDOUS MAI BRIALS AS REFERENCL'!l IN aSCFH§172.202. <br /> µ.. .. ,._ .t <br /> iv <br />