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2601'°N Md :G 0 8Z'3nd zIJJil pzniz3z8 <br />Aug. 18, 2014 1:43 PM No. 1999 f. 1 <br />Toll Free :1'-866.896;.9600 I waive: iwmb.ca:gov1Tires/ <br />CA Comprehensive •Tri Log and �Recept5' 10002 `wua;hla►"' 9.:aew,l:fa,"i,°""en16o61G <br />1 "Pa): t3oi 1269; b`Sc:a'mctito, C4 89eT 2 —1290 <br />Com I`eherisive Tri Number <br />1 i7 INSTRUCTIONS ON BACK OF PART 7' 66 -Of UPF, STAPL� DUdLI ATi <br />By dPA1.0 ON CLL CoaQw,gW.T.1p Lap MO Ceesix Ue e16-1e)nqueel04k1h. W.—Ovo. P•OMOeO OP N,C(oM wU{ Oa car (dNed cynrdMlle), e•0 V600 eoCreL N utord&me Wkh Gd., t![GR ahaUon <br />17°11 el eeq„Ilefe°reelh r'M 00 br04ala0JrOdNUlnfoemDUoo, the LflVNfl rlD aor,tec(UOetOrofld of NlO forlPUNifaWUEanA Rb DDor,e wmGci OtCTdad eglnb fa(1ry .�(w�41: . •d��'. ' <br />Hauler A'ddre$9 � .....: , ., .., , •. <br />�uSIP sS Name %�/9� L �`'' �^t T • s- :. �/ c_ /.Ae <br />City, State and zip <br />1m^%h(u1400WOffydip" vWr00rL1alovodNeState alCadilo Oft NWW7%a—P•o+�e0aataomwaanemr .Lk a pon,IomO-vv •OI to miaW*n."may rma41� P��aril6roa:anddontowtn"lofI <br />v+auOTieMadeePa°�lnV�onaroveMbPvDrolzcmurcesCaaeaedDn�260°pMTaynoJrin6aoend6ee�ywsss,aeopereay.oervlaed:nyegT r oue to15.°Wpot .favic.par oayaaaeavoeornogpVORoM^" <br />Code ee.*w 02962 r '1'� r ,'!;! i`- " r.•� <br />..,.,�."i�' l,tJ�5s�1.-rel �J � •1. ,�,�- � ����;-.�'• ,-:::.�._� r. <br />Driver's arae (print) r„ . - .I ; , '� ,,:., ' 1 :.t , ri Or" .r'_;$ gndture, , Dat <br />3248632 <br />Naulor'Yi6b Program ID 1 Site Suffix' :( FaClllty 1 glaphone Number <br />Wsul2r Name <br />A SLit, <br />ab2t-01Ci . .� <br />!:�{ Same as.Wauler <br />Hauler Telephone Nunitivr oAad e&s <br />I CERTfV THAT UNDER PEM{.T/ of pl"UVRV op jhE <br />l • �• LAMM OF TME STATE OF CALIFORWA TM►T TMQ <br />1 00 •. 1 <br />3248632 :`;,�..7 Y® <br />Hauler Tire Program 10 1 Site Su xI I FOility TOP horte.Numb.Or., <br />Fe WMAVs <br />t �ll9ine5 � �j <br />(Hauler Name v Cii�l�nti 1l `U-vl �C� <br />All1. <br />Hauler Telephone Numbor Address Same as Hauler <br />l�llf <br />XV '1 FI THAT UNDER PENALTOFFERJVRY OP TMf <br />L (1 j IAM <br />AWA OFORMA 1{ON PHON°EO AaPTE TNA1 YM2 <br />248632Tu'llao.:o <br />Hauler Tire Program ID I Site Suffix �. . <br />Facility Telephori� Nym, ' t..�, ►?'� : <br />aQa o F1 <br />Irs Nau a/AdaRs� �� �• �,�.�_, <br />Nauler Na ih I. / Cit J, �t and„ Fi'%� A �� „ ,'> -2 <br />6I9 -E F000/2000d 8917-Z RDISHC dAI1.VEUD-W0H3 Oil : 8L tl ,-8Z-80 <br />