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May, 29. 2013 11 : 11AM No, 8883 P. 3 <br /> Toll Free 366-,89&,q0001 www:ciwmb:c ,oy/Tires/ <br /> CA Comprehensive Tri Log and Receipts 10002 Califoinielr25.9, 40am�nto,Qapgm•nlBoard <br /> P.O,aok 1159,Aactamfiritri,CA 95012—Y259 <br /> E x a M Com Pehensive Trf Number <br /> 541.cIC.rMh <br /> crWia2')'J .Y15)INSTRUCTIONS ON BACK OF PART 2 DO•NOT TAPE,STAPLE OR D •PL6TE <br /> By algning thl_•CA Compr•hensly Trip Lod and Receipt.the dartarts)request that Lhe laform.dun provided on this rorm will be ecnsldereo con/identtal,proprtat•ry-d U4d.serol.In a—,&r. Milt TIL'e,14 CCR,S,,C' <br /> t 7041 el:aq.,17 a request I•made I.,cls-;frr.,rs or Ola Inlom�alfen,the CWl7AE will contact the etnnertel or this term•I the address pad Islephone number provided on this form or rec.Ipt. <br /> HauleY'Addres ��i�ici�Iinc� <br /> E30' in'esS Narrte <br /> I p address ' , /�6, 8ox 1/07 • <br /> City, State and Zip <br /> 6 J y a l '7 C aCom,mon <br /> ,:.:,..Carr-fee<.... . .. .. •. . . . � ;. . . . . . <br /> I crrtih t•ndnr pene,t,of par rrryrender po lacus of'he State o!Cafl(crnla that Ups Inrorms6on ptovidad ehova la w•and wrreeL In aaafticn,l am a,vero bat laleffia:i Ot Pda lntornvacn mpy result In suepencbn,rgvoc9dml,or de.vsl of mnawal e7 In <br /> Waste Tire Hauler Re:?stmgon pursuam to Puc6e Resources Code arcl'on e4360 and may¢:illi In rel penmU:a up Io;15,000 parlay,per vlolauon or,adient rn v v ;i" to$S. per vlotsllon per day as de•.cnicd In Public Rasooroea <br /> Coos sccuon 42364 / 1'l <br /> Driver's Narrie(print) ADr ver, tUff I—�"'�77 �tSat <br /> 3248516 C /) 01.41R.n <br /> ; iR!IJ <br /> Hauler Tire.Prpgrarn ID I Site Suffix Facy Telephone Number <br /> ,I l'af`�Ilt <br /> I i QIWIA31 <br /> Hautme'� <br /> dA^ �.. --�. I 05 L <br /> Hauler Telephone Numbs,` - <br /> Address,Same as HAujer 7 ;rears <br /> M !d I CERTIFY THAT UNDER PENALTY Or PeRJURY OF THE t <br /> UVl6 OF THE STATE OF CALIFORNIA YNAT THE If— <br /> -)� ' <br /> !7/' L/f �••. LVFORMATION PROV7DE0 A O CORRECT. <br /> 324 8 516 . :; :. 1 0 'QARE P H <br /> Hauler Tire Program IDS/ site suffix Facility Telepho.ne,NUh*gr;. <br /> gag RPRWHE <br /> h � � Naahtie�dj re <br /> .Hjuler Name <br /> tn/\ <br /> Ncler7elephone Number <br /> ` Address air es <br /> � THAT Un5 PENALTY b �dF ale <br /> �• _ L= r <br /> Or THE riTAJ,OF CAIJFO <br /> (OV EMIOEO A E l9 RRECT. t <br /> 3248516 " — <br /> +�ii <br /> Fac 11 " umber <br /> Hauler Tire Program ID I Site Sufl f, <br /> F � <br /> D — N r <br /> Hauler camel�- <br /> _( kittp or.t.al5�l IIF :.. , Qv'r.�06 <br /> Hatiler Telephone Nuniber tJ Addrbss SaRie as Hauler <br /> I __,iusi iwbeR PENALTY OF.PERJURY OF THE / . _ <br />