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TION TPID 1003974 ".�,�. PLEASE REMIT TO: <br /> 001 I Vasco Road _ _ saa tasaa cea cs: P.O. Box 83328 <br /> Livermore,CA 94551 � ' �_' '� '� Portland, OR 97283 <br /> :(925)-447-0972 P . WASTE RECOVERYWEST. INC. <br /> 1-877-OLD-TYKE <br /> Fax (925) 456-7794 Hauler ❑Generator ❑End Use Facility ( <br /> invoice Date (��_ ��� Load Date a- _ / OPhone# 1V Pickup <br /> Delivery <br /> Customer Name; / Acct#_.� __ <br /> Site Street Address ��DfJ rp �'� City_ / StateZip_�, � <br /> DRIVER I certify that under penalty ofperjury under the laws of the State ofCalifornia that the information provided is trueand correct.-In addition,I am aware that <br /> falsification of this information may result msuspension,revocation,or denial ofrenewal ofthe Waste Tire.Hauler Registradonpursuant to Public Resources <br /> .� Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as <br /> XpL- ' ,-- described in Public Resources Code section 42962. - <br /> Hauler Exemption _ ❑Government ,❑LEA <br /> ❑Agriculture- L]Common Carrier - - <br /> JRUCK#' HPULILER W TRLR H TRLR#' D IVER/HELPER MANIFEST H# -CASH/ RLE <br /> ( / <br /> LIC PLATE# DECAL# LIC STATE IMPORT ❑ LOCATION CUSTOMER TPID#: TRIP LOG# <br /> 769 EXPORT❑ <br /> LOQUANTI YNT - Description - TYPE Rate - Amount <br /> C-T-Y-P <br /> AC <br /> POSTED <br /> '�T A�f�r TDA <br /> Customer Signature Total Amount$ Cam <br /> Icertify that under penaltty ofpeqi�y under w <br /> the as ofthe State of Califomia that the information provided above is true and correct.In <br /> m - - _ <br /> addition,I aaware that falsihcati5n ofthis information may result in dvil penalties up to$25,000 per day,per.violation or administrative - - - /'+ <br /> _. p naltics up to$5,000 per violation per day as described in Public Resources Code section 962. I N VO ICE C 21676 <br />