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r3O38 6 4 8 3 UP-- Delivery RE-[ <br /> a <br /> ) Hauler Tire Program ID / Site Suffix" DATE � r ; Facility T�ephOne NUm.bel <br /> c. w Whole The Count Weight HE, <br /> In Lbs _ �� <br /> g Facilitytusirt, . <br /> olume Cubic Yds Weight in Tons <br /> i l Iloll ' Name/Address <br /> E. s , . <br /> o.. <br /> City, State an cf Zip <br /> Hauler Telephone NumberE <br /> Stamp or Label OK <br /> d'3 06 o <br /> - Whole-Tires Only _ I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> for WI10Ie Tire Count LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRE< <br /> X. <br /> U.a <br /> J <br /> Uj <br /> � <br /> / 1 <br /> cn IMC?-i U 1 Z <br /> Q � z ' f.W <br /> Uj40 <br /> 0 LL O LL <br /> C ca <br /> C5 v z o 7iN <br /> o ri LU E <br /> . 1 <br /> LLJ <br /> Lr <br /> ~ o C <br /> 0 m O r <br /> LL <br /> LL <br /> CL <br /> E �F <br /> v 0 z Q <br /> � y <br />