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OCT-14-?005fFR1 1?.a? �F,�� �0836088�6 P. 00? OOa <br /> I L1._., CA 95240 Manlfest.Number• <br /> (209) 333-8442 <br /> EE <br /> : - 2.4 ;5.. . _ 51 _ <br /> ' vriil eq'eonstdnied t�lntldeniiat',proDnGtnry an'drar a'tritde <br /> CIWMB wiiFr6niao(tl+o•Slgnei(s).al Iris format lha audress <br /> CUSTOMER'S ORDEn NO. PHONE E i, .'• <br /> ev <br /> -`�' �" ' PLEASE�pRINT`FI) 411LY <br /> NAME <br /> ADonE ALL IMAGE TIRE <br /> Cherokee Lane <br /> • Lodi,CA'95240 <br /> GOLD DY CASH ICHARGE ON ACCT MUSE.nETQ Il PAID our (209)333-8442 <br /> OTY. DESCRIPTION PRICE AMOUNT <br /> Hauler Exempt16n4iuppii able) , <br /> I].Gov omment LER F,ltempl <br /> .' Q Agriculture 0 Common Carrior/ <br /> Back Haul <br /> ' / I Indicate•tit tippucablo} <br /> 3 Unregistered-Hauler <br /> nd correct.'Irl 000lUon,.l arft aware lhei fWS144s11bn of this <br /> — —— ----- -•--•------- -- - ' �ublic Resourcei'Cod$st:dlon 42g6,o and fray result In civil.. <br /> ' lri Public Rosouices C000 aecliori <br /> Date <br /> UC r: <br /> R 'SaEN.Ei{�TOR <br /> s <br /> U EF ' I' ' <br /> ��, .. ,.. .., '�;.; :p�:�A$E�PRI[�Y':FffiMLY_ <br /> Ml: -•, �'S BtislhesS Phone (Include area codo) . <br /> :I <br /> t , <br /> Warranty: <br /> T <br /> --------_--_ .. Zip Code_. `a Address Gama A.Hauler <br /> - -- ' " <br /> I,l <br /> I <br /> o Warranty On Used?fres- TAX p 7 <br /> RECUVCD BYp• , i rTAL - •u. I :1�s•� (_,_) �O Change Ot Address <br /> : 08@ mo <br /> uOtt <br /> All Clal,Is and returned g00ds MI161 tie eceomnenlB by Ibis bill. ' : ' " <br /> To Rtladar. l llank��� �" t l i "..i. I (a' <br /> ti00•Z74 87eo ornate t oto 1"(n"fi�IF15 �,r A :1Ntible:NtJr�jlii3rg driljl. ,: Cilihal` <br /> -•- .+r-..r .r..�..+-..-w: _ �ti'... i F`:4_�°_a?4} IOf�h4l jliB*6Oh ',:r-.:.•,;.: <br /> .,._. .. .--_ .. .....Y..� ,- -- - - -��,_..r.��_ <br /> � `Pa g rtroti �; _'�Y.b BrtiC28:r R UA9:'' ;• •i � �..,• ,�:';' <br /> „ ssen e1A I ;'; r 4 i /3rtidurtl I QReueadtR�use" Aeeydo:1; 4[;Fyel,...�Q;.[flgpbsatllandllll <br /> r <br /> •c <br /> 1- <br /> ,I.• I <br /> I wAtry toot un0er pendt� 1.Dequry Undat Inc Iowa of the Slgle of Callfar►1l that the InIO�meUon provided above is true and'oorreet..ln ad�lticn,t ajn auiraie�I�l fa1SIIIcaUctact Ihrs...•. <br /> InlomtaGOrt may result 1R rd II pen011'es up to Eu,000 Per day.Par vioisilon or pdminislielive penallle8 up td 55,000 per violatlon't>ar'day d5 Oeacrllied in Public[aesaujt s.Cooe, <br /> LDnlon 42962. .. '• _ •. ... ;, <br /> t. <br /> Representative N 3me(print' Representative's Slgnaturo', ,:r :Dt�te. - 26187 <br /> Totf•-Free1-866-896= 600.! .. .w.ww.ciwmb:ca:govlTiresl <br /> While:CIWMB Copy Pink:Tiro ealvdGunerarorlEnd Use Facalily CODV .Yellow;Mauler GOOY: <br /> i.Rernove top stub 2. Fold Irl half at told Ilne 3:,Pemove adtleslVestrJp-.. .4,•Adhere romalnirig.stuti <br /> ora.ii�r n�..nur"*ure:eTt in - - -- —. . rrr nv ru nrre.rf — <br />