|
Deo 16 2004 4i54PM HP LAS ERJEEF 3330 9. 2
<br /> Fa=t=w4ff"W1__ -IF"t
<br /> 0J.aA:34Hh: 0 at
<br /> R, aL SNL,04132� 0 3t60a -j O.L 3,jVcf? C.1
<br /> VisaCswair!s irdog-ated vvaee Van%;o-err 6:art
<br /> 'CA Uniform Waste and Used Tire Manifest P06,,126D. Saorar-14nto,C.A �58i2 269
<br /> NE
<br /> I C AIM! P IManifest Number L_ FE
<br /> 5 4 0 0 1
<br /> INSTRUCTIONS ON BACK M I
<br /> j 'jD 'f' " . -.
<br /> PART I: BE COMP!11TV BY' t1litf.HAULEA.. ipla1aft print)
<br /> Ll Plick,up
<br /> Irnpart!rom
<br /> befivery
<br /> I-Export to
<br /> Hauler's 8,jales P�zme
<br /> W outIldil (Include area code)
<br /> -sHauler Exemption (f OP01 Cabin)
<br /> / 0 1 S s E,Government [: LEA ENrrrpi
<br /> Load Date IrAliijizD/yy, Log Number
<br /> AgrIcUftV8 Ej COrrf-:n Cp1r:firl
<br /> 0TI </ Cl—414 indlc&ta(I,,appiicacle F.1 Ir Trans,
<br /> License Plate Number -state Decal Number
<br /> 7Con f Ideritla lily C18IM: Ths Irforrna'.1on p-7vidd4In Pert I ard Per,It of this form should beconsiderod conildaniie.p(cipirlatan,,and/o,taze secret, I",
<br /> 3ccordarce with,Title 14,COR,Section 17D41 al-aeq,should a-iy-iiarnbar of the pul;I1c.-ejUa6-.disc:csuie of this:rllormavon,I request ii-at cm is contact!
<br /> Ta at the address and tapphwie ru_rrbqr above.
<br /> .6mly ti-6,urloa?Poralry -IQ lift Of the sts'.01 of owecirnia Inal IN In
<br /> cr ,ha Nate7trea auier Ae
<br /> at
<br /> cava eas P!c SZ,ow per day,per vioailon*r admhstr&,i,,*Pwia ties-)p tc MOM go r vivaison p f 916 d95 In It 0 loUrcei Code dad Icir)4256;.
<br /> .5
<br /> river's wame(print) r We P-s- tu ra rDa e
<br /> PAIN II: T05CCOMPLETEMSY:1111EPAE, 12"'TATV4*�t egATOR OR 5ND.USE
<br /> FACILITY(pleoe print)-USE ACTUAL LOCATION WAME THE.TIRES Ak-Ip1�
<br /> KEOW O'R. DROPPED OFF.
<br /> 7
<br /> S,C
<br /> Business Name
<br /> Facility's Business Phone(include cree Ec
<br /> &S� a` . w—_a_1Is Z) N Q Z,
<br /> Number&Street Address
<br /> C:'Aftasa!larrs As Hadoe
<br /> City slate zip Code
<br /> Tire Types and Amounts intended Use
<br /> e 2, M Passongewr
<br /> Tire Program ID site Ufflx
<br /> Load Type(check only
<br /> t"Ii
<br /> ❑Wholo'Tra`Gcol W610h0n:PoLo .",I .Y;
<br /> ruck ❑Other 0 Fuel:
<br /> volume.tublo YArds' El wilasti in Tdo"s '] I.
<br /> Load Amouht Comment Area
<br /> fA
<br /> OConlicientialityChaim:-ha inforfr,all.^nproyldodinPart I and Part 11 of this form should be conaldered:cnildatift,proprietary,arcAortrade se-cm.
<br /> In accord ce*1111 Title 14,OCR,S61lorl 17041 et.saq,should any rriernber of the public request disclosure of this Intonratlor,Irequeal:thr.CMUS
<br /> contact rre ntzh@ scidreva and i4loprione rulmLior above.
<br /> CeVythst undq-penslrto?perjury under ft:jphii of QV State of C-4111tomil that the wmalanpwitled 000ye Is Pull ffird correct,In accillon,I artii aware ins;fawwon Ot IN&
<br /> iforrvitipp irair revue in arvii ponaii:i9i up to$96,000 per dal,per Wolatim or rdrrdn:@trsijv4 perwiss up to$5.000 per violation Per dee asawribeci in Public Rascureat Code
<br /> n 42"961,
<br /> RePrOSerltatiVe Name(print) Representative's Signature Date 312876
<br />
|