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-n <br /> (D <br /> s <br /> m N <br /> n <br /> CD <br /> Q N <br /> W <br /> — 7C) <br /> T <br /> NNU // K <br /> 0 <br /> o a4 3 8 0 7 6 9 -- C Pick Up Delivery1 V _ o <br /> 6E <br /> Hauler Tire Program ID / Slte suffix <br /> DATE Facility Telephone Number <br /> L <br /> W a, <br /> LLI Whole Tire Count ' Weight In Lbs. <br /> oar ® <br /> E J` Z Volume Cubic Yds. Weight In Tons �.J /(� /�C© U2 T it <br /> ry <br /> a,uler <br /> 7oi?;337C1710 ;a!;��r,_;:.�� ■ �� �.�ii�isl�s��,elr• �r-�;6 _� <br /> In <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Wholo Tlret) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> ' --�-- INFORMATION PROVIDED ABOVE Is TRUE AND CORRECT. <br /> Light Truck Tires $ $ License# g~ <br /> Truck Tires $ $ <br /> Misc. Tires $ $ <br /> Wheels $ $ Payment Information <br /> Trailer Placeen $ qCash $ I o <br /> Trailer Sw ch $ $j Check $ <br /> G)v <br /> Trailer Rem $ $ C° <br /> Charge $ � ' <br /> w <br /> al Due ;- r•,•r �. Total Received $ I o <br /> Driver ` , <br /> _ Customer ;_.. _ Y- <br /> Signature: <br /> Signature: <br /> !� / ,.., <br />