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C:^ ~' & E Com rehenSiv�Irl �NtlmberC-.N "°^" INSTRUCTIONS ON HACK �Y 3OZ <br /> """`�"''°"°4OF PART 2 T T E AP O UP <br /> Ply No"h%,D+I.CA Campronw nw L.a And Auc«n m• <br /> TTaa+YL wy it royv+rl Ia nwub far dlscio.un of JJ.Igpmai,ypl,ylle ~a uw Wor.n�llbn pro.— on fil.pnn WII be conWo„ne co r <br /> IYYIA9 will iOngOL U.•f011.1(11j OL tl+la k ml Yt Uf•.d nA'�"i0a'.a var�•Iary w+U uw.Jwcrac N+mard•nm+Un ns.,+�cck,avwan <br /> •hoe rrW Healon.numaa'vroHaaf un YW Nva.ur r•eape <br /> Truck Decal Number Hauler Address <br /> -� <br /> Business a <br /> Eli � ess N me <br /> - <br /> License Plate Number -• r' �- <br /> State Address <br /> QOC1aD Q0 <br /> • City, State and dip LL. <br /> ' � • ' <br /> �rwy�np�a.il•Irapa„YnY,+w..uw4waxY+.alewaaml � -� <br /> C. <br /> WC <br /> ,42l,tiuyavo0o pure+]A w P w Ra+Wr 0f1, n 4lea Gw tuella,y UK <br /> gn ON <br /> tl YW W-CON -In IOd01C•,1 arR Irgv. <br /> coa„wcaa asst ,../ ,! �°? 44,Von Aseep.np Tey nnux In owy p.naww vY 10176.000 OM Uoy.Oar Wau+ ° <br /> + .Cvy on.:l U14 klarq,rlipn 111Ly iwWl n suaY1xW01,, .nlpd0al,Yroav:J vl ratiMa vl rn <br /> % ••,,. 9''O�'�+*ivao..;pw plkz,+v V 15.000 w Vk” o•r any n o..anbuJ�n c�,nYc Fxou . <br /> Driver's Name(print) — - ""_" ' <br /> Or er's SSignature Date <br /> Q 3 0 2 714 0 Mw C Pit:k u <br /> •�, p Delivery <br /> Hauler Tire Program to 1 Site Suffix t f <br /> Facility a hone umber ' <br /> DAT / � �� ' I <br /> 10 hole Tfr ount Wei ht In Lbs. <br /> 3 a.� l r W r`--J <br /> Elr ✓' r ° ' olume Cub[ ds. Faeility §Jness /r? <br /> E c J ❑W �ght In Tone : <br /> c e/A reds <br /> � Ha I hone Nulil er 4 City, a anti Zip" <br /> v � v� r i <br /> Starpp or Label K T ti•�� [ <br /> Whole Tires only ` I u,;uAs <br /> ttMTIFY YNAT uNDEI<PENAII'r OF YfikJURY OF YME <br /> f0(Whole'Ure Count <br /> ..-.... ........ LAWd OF THE STATfi Or l'.ALIFDILNIA THAI,TNE <br /> INFOA nON YIOED• 1JE•+b'xiUfi ANO.OARi+L7r.-„,«. til <br /> x <br /> 3027140 B Pick Up Deliveryr <br /> , <br /> E.1 <br /> Y Hauler Tire Program ID / SiteSuffix �} Facility Telephone Number <br /> GATE ;` Q � Da / �I� I i <br /> J whole Tire count welgnc In LbE. <br /> Volume Cubic Yds. Facility Business f <br /> Weight In To <br /> Name/Address <br /> Hauler Telephone Number may,Z"Ca <br /> /' 0 i <br /> rrtabel OK. <br /> Whole TILV I cfiAnar TNAr N ! l nrn•r: <br /> for Whole Tire Count LAWS OF TME STAG CAu►OA/•AMAT TILE Of TNS <br /> UJFO MA7 PilOY100O ABOVO T AND 06. CT. <br /> r3O <br /> A ••14 0 A I Pick Up Delivery <br /> Program ID / Site Suffix <br /> �� �� Facility Telephone Number <br /> DATE r� j ' <br /> / /t ; , / ;.. 1 Whole The Countight in Lbs, 0_01000000 <br /> Volume Cubic Yds. Facility�/siness <br /> Weight In Tons J+ r <br /> �ralY, ed Z�I1� <br /> Hauf¢r Telephone Number - <br /> r.Iapel0,K,. <br /> Whole Tire*,Only I CE*Tsv THAT UNDEK P ITY OF PEINUkY O/THE law f A <br /> .. for Whole Tire Count. LAWS Oy TKE STATE OF GALJFONNIA TNAT TME i <br /> ...._ ,•,•, All WFOMNATION P#tWOM"Ove 1 TAUe AND COKAECT. <br /> l� - --. _ ......_.. <br /> Toll Free 1_a66-896-0600/www.ciwmb.ca.gov/Tire3/- <br /> I-Remov®top stub 2. Fold in halt at told line 3. Remove adhesive Strip 4. Adhere remaininstub <br /> "M NO.. -losew-ciwae DO NOT REMOVE THIS STUB g <br /> VO 39Vd d0I SS9868660ZZ�L=� b0':LL L00Z/8Z/Z0 <br />