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NOV/17/2015/TUE 09: 52 AM JSG cking FAX No, 209-3 °-0879 P. 009 <br /> fir,: ; eft ...:L , �v +: >1y`�.7:�y�•��,�tf nn <br /> 5 2 0 <br /> 0520 -- q <br /> Fac"h Tele hone.EVu <br /> Hauler Tire Program ID / Site'Suffix: ;�fds D �� { ty , P I nlber <br /> vg d'S V� H6 P-7 F1 <br /> w W olalre h J <br /> ft1 2 s IM011 �v ?Y �❑''wvfi7 i.,l•, l,i <br /> nil±r�❑Yolum��CubIQ� .i❑1e�gh�lnYa!si <br /> • <br /> E Hauler Name CA 61 <br /> U V>fia "A VT IDy L h 41 r <br /> Hauler Telaphone plumbar ■ ❑ Address Baine as Hauler iDmal <br /> (N/A it Lq,N OFTME STATE OF THAT UNDER CALWORNIA THAT THE ALTY OF PERJURY OF THE <br /> wnofe TIree) <br /> INFORMATION PROVIDED ABOVE 19 TRUE AND CORRECT. <br /> • • - • • • . - • • • • - • • Y <br /> a <br /> 5200515 -- Bj Ypick Up Delivery <br /> 011 Hauler Tire Program ID!,/ Site Suffix ' {' . Facility Tolephone Number <br /> DL <br /> a' Lu, <br /> aof 1 1, to � ;;❑�folumeCublc; �1g WelghtjtliTons I ;Tgr]t2�����, <br /> oHauler Name - - `` <br /> r, Gt2 °� 'Pry Q e �Fc:c� 5'LZ d <br /> Hauler 7elaphorye Number ■ Address Same as Hai f�;r;�r.: <br /> �) /1 U•j;A fO� I CERTIFY THAT UNDER PENALTY OF PERJURY O, ..,2 <br /> �/1 <br /> ` Vp WhOIQ Tires,). LAVIE OF THE STATE OF CALIFORNIA THATTHE <br /> " ' �,•„�,•4� INFORMATION PROVIDED A90VE IH TRIJR AND CORRECT. <br /> Pick UP Delivery N PiR N ® � <br /> 5200507 A F11 <br /> I FilitylTelgphorle Number .i <br /> i e •. 'fes' :. <br /> N Hauler Tire Program ID / Site Suffix DA`f� �' 0ac. <br /> r � U❑�� OLJILIJI <br /> TAS cati WesiL h fi bs i, <br /> •� :".l .^'•:i;. ;J�. .r,.;'i .�. R 1 ;t Sz.3„{off w '�W j ^� � ��,,� �,K �(F�? �v U�� V1 <br /> , 'Voi �1 fli. 1111'1. b •f I Cit . §,��� ,�'�t •j�g;r' p,� <br /> �{ rE�” „`.jA s„� 14N 1.b,Ct. <br /> • , r <br /> oHauler Name � ��. �r1 � <br /> �j C7G17i :W 414 06 Ct <br /> a Addr'ess Same as hauler IrW.1_ <br /> HaulerTelsphoneNumber lNAkfor ICERTIFYTHATUNDER PENALTY OFPERJURY OFTHE <br /> U� Whole Tires) LAWS OF THE STATE OF CALIFORNIATHAT THE <br /> ` INFORMATION PROVIDED ABOYE 1,5 TRUE AND C,RRECT. <br /> Received Tlme Nov, 17. 2015 10: 08AM No, 1421 <br />