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S Working for YOU VOUCHER 2011 Local Government Waste Tire Clean-UO Grant One Time Permission to Haul To Alternate Disposal Site I certify that I am the legal owner or authorized agent of the legal owner of the below described real property. Number treet Cit and Zip Neither I nor any licensee or lessee or person I inherited from personally brought any of the subject waste tires onto my property. Nor did I direct, authorize,permit or otherwise provide consent to another to bring the tires on my property. Specifically, to the best of my knowledge,the circumstances of how the tires were brought onto my property, and the manner in which I/became aware that the tires were on my property, are as follows: iGS �� el n/ ftp ru �- ti's ueo- I understand that by signing this Voucher, I am not admitting liability or responsibility for the cleanup of the property clare, uqAef penalty of perjury, that all the above information is true and accurate to the best my ovule e a d belief. Signature Printed Na e Telephone Number Date of Signature The tires hauled will be managed under the Local Government Waste Tire Clean-Up Grant Program. You are scheduled to haul up to 19 tires to your assigned location on: Date: - � ( _ Appointment Time: # of Tires: ! Please complete: Authorized by San Jo quin Cott Public Works # passenger tires with rims: Solid Waste Division (209) 468- 066 #passenger tires without rims: Copies of this form will not be accepted. #truck tires with rims: # truck tires without rims: # larger tires (with paid fees): Total tires: �Z (Must not exceed #of tires scheduled) TO DETERMINE ELIGIBILITY YOU MUST REGISTER FOR THIS FREE DISPOSAL EVENT - CALL (209) 468-3066 Issued by San Joaquin County Environmental Health Department. Made possible by a grant from the California Department of Resources Recycling and Recovery (CalRecycle)to San Joaquin County Department of Public Works.