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-11 <br /> cD <br /> a- <br /> N <br /> < N <br /> CD O <br /> --1 W <br /> -- VI <br /> Tl � •� <br /> CD <br /> , I54 -- A <br /> �211 <br /> Pick Up Delivery <br /> ti Facility Telephone Number <br /> F<Iler Tire Program ID / Site Suffix DATE <br /> o <br /> . ooa <br /> _ goo <br /> u Whole Tire Count Weight In Lbs, <br /> Volume Cubic Yds. Weight in Tons : '.r <br /> D <br /> 9 r� S. SqC,4. <br /> 0ODE0. <br /> i'Sc�C1iF1'�Ji''.1`�:i:I�;l.)�r'w YUUnI}:t:'.1• <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> (NIA <br /> Whole Tires) tlws of THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE Is TRUE AND CORRECT. <br /> i <br /> IYIIA1i, I ues $ $ <br /> Wheels $ $ Payment Information <br /> Trailer Placement $ Cash $ <br /> Trailer S I h $ $ Check $ <br /> Trailer Re o I $ $ Charge $ <br /> otal Due = Total Received $., <br /> 'r Customer.. o <br /> ature: - Signature: _ W <br /> N <br />