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_J_ --JLJL <br /> 100 <br /> U Address Same as Hauler initials yr <br /> {� t4.Pi'iY` Nt.t3r - _ _L L 1 CEtiTII^/THAT UNDER PENALTY OF PF3iJtJRY OF THE <br /> -te (N/n to LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> Whole Tlrea) <br /> iNFORMA'rION PROVIDED ABOVE IS TRUE AND CORRECT. I <br /> • • i <br /> nk 4 IFFJU�M-1-11 <br /> t. 1 Li <br /> --i Facility Telephone �liarnber <br /> !-�a�tie+ Tire Program lIJ Site Suffix I r- -� i T----'i - <br /> t F I": <br /> [( i , a Weight in bias. _ ----- <br /> LU L� 1.hole Tire Count 9 <br /> i" E VOILIMe Cubic Yds.� Weight in Tons <br /> oo <br /> Q ! R rlairragC € f.m., �S N£!Rl�t3T Initials <br /> (N�A tot' i CERTIFY THAT UNDER PENALTY OF PERJURY OF THE _ <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> • • • <br /> L-01". 1 • <br /> - t <br /> 7. 1 �,. Pick Up ©elivery - El <br /> _. <br /> Facility Telephone Number <br /> 4 L <br /> hauler Tire Program ID ! Site Suffix DATE <br /> Ell <br /> J _ f <br /> W -Whole Tire:count , []Weight in Lbs. <br /> Weight In Tons <br /> Volume Cubic Yds. — tr <br /> t <br /> t <br /> CERTIFY THAT UNDER L <br /> Lj <br /> r t'C'rsr?Sr� ::A '4 Initials <br /> loo <br /> ()nc Number _ - _ � PENALTY OF PERJURY OF THE - <br /> �- (N/A tOrLAW'y(SOFFFTT�HE STATE OF CALIFORNIA THAT THE <br />