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INSTRUCTIC',_ <br /> "`A1lT l: 10 4/R.: C®{VI P".i...E�3f�';.Bp�_.TI <br /> RE ("1HU1..E ..�r S�IfIr� <br /> — e <br /> j import frorn <br /> (11 oµtNirle� ;r.;mla `>I <br /> Delivery <br /> s s <br /> Export to � ,,. '},�--r- <br /> (it <br /> L. (,tp�IOPI if nr-- —� 1 mLOadQatg(MM/DD/YY) ��g _ ❑ LEA Exe _ <br /> - <br /> -�---T <br /> 1 I ` I ❑ Corraw�r seri <br /> Plate Num i� <br /> Back r# <br /> - E <br /> :. � -- � I_.... i � tis <br /> 8 <br /> LiLens� liar - t 3� � � Ir�ic3te -if applic�v . ,_t.�'aansit <br /> _ _ - State �.e�-L, r.� _ _ <br /> Jer - <br /> CIConfidentiality Claim the information - <br /> accordance with fill, 14. CCR, Section 17041 el-segpshoutd anyitier„•, ”A" piietar; and/or trade secret.. <br /> Me at the address and telephone number above. vet of ir.<PAiblic rec,est;!Sciosure a i <br /> jquest that CIWNFB contact <br /> I certify that under penalty of perjury under the laws of the State ed <br /> nionnatfon may result in suspension,revocation,of denial of renewal of the vdast <br /> penalties up to 525,000 per da California that the infosrrar <br /> on provided ab,ve a true and correct, aaoa.cr.,I ant aware that falstflt rt,;in of t11is <br /> y,per violation or administrative penalties u e Tire Mauler Regist a:or pursuant to Public Resources Code section 42960 and may result in civil, <br /> i/t P to$5.000 per violation _ l <br /> per day as described in Public Resources Code section 42962. <br /> DtiTO BE- <br /> CQNfPLEEC R4'1RfRESENA7IVS C T1RF_ DEALERver s -OR <br /> -- ----- <br /> r ,fL1"T (f�i .ase print) - USE ACTUAL LOCATION VVf�ERE THE TIRES data- -- <br /> a�F S lE FIRE GENERATOR OR END-USE <br /> RES ARE PJIC;(ED- F OR DROPPED OFF, <br /> Hess --- �Iji7i usi 1V�a��;eF{aci3it — <br /> Y s t3usiness Phone (include area code) <br /> Nwao ager <br /> tic StreetAddr <br /> ess <br /> J <br /> City <br /> A i El Address same As Hauler <br /> State - _ I ❑Change Of Address <br /> Tire Types and Amo <br /> Tire — Z►p Cade -- <br /> _-----___ <br /> ID <br /> ❑Pasenger mounts <br /> - <br /> - - ended Use <br /> sfe -•_r#fix i �- _�.— ❑Oversize int <br /> oit_oad Type(Chr)ck onlyns -1 - -� <br /> — - - Retread/Reuse <br /> ount <br /> — -- --� <br /> [�VVei ht in P `-I Truck --� --- I'J i <br /> V�rliiin ! g ounds M <br /> _ — L_ ❑ Recycle <br /> ubir;Yards I 1 _ ❑Other <br /> Weight ur Tons o r I-� r <br /> Load.,Amount � I i I I ___7_I � ❑ Fuel <br /> Q <br /> _ -- <br /> } Comment Area <br /> Disposal/Landfill <br /> nConfidentialit <br /> y Claim. <br /> I lie inroutiation provided in Part I and Part II of this form shout <br /> In accordance with Title 14, CCR, Section 17041 et.se <br /> contact rhe at the address and telephone number above. <br /> G, should any member of the public request disclosure Of this information I <br /> d be considered confidential,proprietar <br /> certify that under penalty of perjury under the laws of the Slate of California that the in Y.and/or trade secret_ <br /> information may result in civil request that CiwMS <br /> section 42982 Penalties up to$25,000 formation provided above is true and correct.In addition,I be aware that falsificattprt d <br /> per day,per violation or administrative penalties up to ova is <br /> r. per violation Per day as desc load in Public Resources f this <br /> coag <br /> Representative Name -- ---.---- F <br /> (prnw) <br /> Representative's Signature <br /> d� !MToll gree 6 / fate <br /> VVnft(­_, CJVVMBWVC/9nP C1� 32876 <br /> Copy Mb.Ce.9OV/Tires/ <br /> fiat k3%tN�a <br /> Q � <br /> -=-•+ ��, ,. r l' w .t a Fs's FORM NO.M,7n.r�oc- <br /> I , <br />