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573 6 8 8 5 ®® B ®Pick Up ❑ Delivery <br /> N <br /> � 2 <br /> ❑ ❑ �❑ ❑ ❑ <br /> Hauler Tire Program ID / Site.Suff9di jY ` F <br /> I DATE 1( aJ �,I / j❑ S Telephone Number <br /> LLLrrrJJJ'�tatL.�LJ'11,.• _Nn <br /> TFID# 1471M-pl 1,) tu Wholejy'C int Wei tit in Lbs. � NN <br /> � ¢ s ❑ <br /> e ° . Corp Fa.cilit 11 r `�, Cp.j( <br /> ' f' I h h Wl iQubjc Yds. Weight In Tons �J" <br /> Hauler N01 <br /> � ' �-J ❑ 9 Name re -, _A <br /> cPtx,�er3,CA X94621 City,Statt�c 1p as Hauler Initials <br /> b(510) 569-9500 rtU <br /> C <br /> a S?ai � �3 <br /> Hauler Telephone t�lulTlbe-r ■ Address Same" —� <br /> ❑ <br /> 0001M,:00, <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE 15 TRUE AND CORRECT. <br />