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CIWN113-60 (3,06)- Califor -ttegrated Waste Management Board <br /> ( J. Box 4025 - Sacramento, CA 95812 <br /> .APPLICANT: This application is a: <br /> CIFiMB Use Only <br /> ` <br /> Vets Application Chanlc in Vehicle Ownership [� <br /> Reviewed <br /> Renewal ❑ Change in Business Ownership and/or Name By <br /> ❑ Date <br /> Issued <br /> Add/Delete Vehicle ❑ Replacement Decal <br /> Waste Tire Hauler Registration Application `n ' <br /> Pursuant to Section 42950 et. seq. of the Public Resources Code, a waste tire hauler shall submit the following information on this orn; <br /> order to obtain a Waste Tire Hauler Registration and approval to transport used or waste tires. <br /> APT'1-IC,4-N"T COMPLETE(TYPE OR PRIA7 IN INA-1 17TAf 1 THROL`GH 9. IFA SPECIFIC ITEM DOES NOT APPLY TO YOUR COMPANY, ENTER <br /> "A'/A FOR <br /> ,u <br /> APPLICABLE INCOMPLETE OR PHOTOCOPIED FOR.14S,1IA}'RE REJECTED. <br /> 1. Business name of company`: <br /> 2. Business Owner: C_Tx r 2.a <br /> / Phone Number <br /> Social Security Number <br /> 3. Business Operator (if different from Business :Owner .- . ' �- <br /> ) —_ � �� G-�_. / Phone Number .�----- <br /> 4. Other business names of the company (DBA's): - <br /> 5. Mailing address of company: _ Ll" – 6 s – <br /> C.'ity_�`� `_� C�' State C' ---- <br /> —i �_ ZiP <br /> h. Facility address (if different than No. 5) � a <br /> City State Zip -- -- - <br /> Vehicle Descriptions: Provide information for each vehicle to be approved to haul used or waste tires on page 2. <br /> `�. Attach proof of bond. (Form CIWMB-61) ` <br /> r 7- <br /> 9. Indicate prospective end use facilities (disposal, recycle, storage, etc.). If you need more space, please list on a separate <br /> page. <br /> ame. Address <br /> rY. ..�� Phone number <br /> X0 l�''%`a ' G f� t _ z <br /> ,M711ae of individual, Sole proprietorship, co-partnership, Limited Liability Company, corporation, or political subdivision applying for registration. <br /> hur>uant to ramilq Code Section 17520(d.i.persons applyut<&,for issuance or renewal of any license or other authorization to engage in a business,occupation.or profess r <br /> 1,101 an)of the laws administered h}the C'IWMB.must procidc their social security numbers to the C'IWMB.The CIWMB uses this information to match their names to th, <br /> nuts on the list provided bs the Department of Child upport services. and to respond to requests Ior informati Lade by child support agencies. <br /> certifv un r penalty f pet'j4underaws ofthe State of California that the infor atio on this application form is true and correcti�=nature of authorized gate <br /> I itlted Name of Authorized Agent Title of Authorized Agent <br /> Icgki;,ajon application lee is required. Incomplete applications will be returned,and applicant will not be considered registered. <br /> T1�RN COMPLETE REGISTRATION APPLICATION TO! Tire Management-Branch <br /> Special Waste Division <br /> f'aliftrrm2 IntPorarari Wactr Manaawmt-nt Rnard <br />