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Rub 13 04 04:52p @ 2094630199 p.2 <br /> ffr• 1'E J K(A M f P L I E I I [,j tmannesi numtoer: <br /> ka <br /> Stele OI CiM1tornia INSTRUCTIONS ON SAS.. •`, 8. . 1 .v 1_8 •0 <br /> CIWA19-647(0W03) t� <br /> Mauler (opGpn�al-Address I-abet) <br /> Business Mame trtl til •I <br /> r; r, <br /> x G t i Address `� r <br /> fJ Mauler's Business Phone <br /> (include area coda) LMHauler <br /> I_ Dq / Lol— 10:1 0 GovernmeDt EA Exempt <br /> ion (if cablej <br /> —L�--- <br /> Load Date (AM00 YY) Log Number ❑ggrieul2ure (]common Carrier! <br /> T r Back Haul <br /> Indleate,(if applicabiey-0 In Transit <br /> License Plate Number_ State -- Decal Number <br /> OConfidentiallty Claim:The information provided in Part t and Part It of this form should be considered confidential,proprietary,and/or trap secret.to <br /> accordance with Tide 14,CCR,Section 17041 et.seq,should any member of the public request disclosure of this information,1 request that CIWMB contact <br /> me at the address and telephone number above. <br /> t cerfity that under penalty of perjury under the taws of the State of Calilomia that the Information provided above is true and correct. In addition,I am aware that falsification of fills <br /> infomlation may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil. <br /> penalties up to$25,000 per day;per violation oradministrative penalties up to$5.000 per violation per day as described in Public Resources Code section 42962. <br /> Drivers Name(printf Drivers Signature Date <br /> -mrw, w _"��3• <br /> '8 <br /> 1.Te� 6 T� -J, <br /> Business Name Lacfllt�.s Business Phone(include area code) <br /> I <br /> !�._.._I :I___..� .__l____1____1_.....j;__.._L_ ._I.. ..1.._...1..._f•I_._l._.._J.;._.1.._.._L._..J�—.1 I>+ I�„_J,T_t��.L_1.:._.J. a I _ i—..J�.I <br /> Number&Street Address ; <br /> L []Addresd Same As Hauler <br /> i 1 I L ► C 1 J _ i f t r©Change 01-Address <br /> City -- -- - - - _State Zip Code <br /> Tire Types-and Amounts Intended Use <br /> ❑Passenger r[�Oversize E]RetreadlReuse <br /> Tire Program ID r ISite Su ix ff'' <br /> F 1 <br /> -l0 ' _..._El Recycle <br /> 0 Truck 0 OtherFL <br /> Disposal/Landfill <br /> FLI, 1. <br /> Comment Area <br /> 0f;tsnfide4ia1i C:The information provided in Part I and Part ti of this form'should-* nsidered eortfidential.proprietary,andlor trade secret. <br /> In accordance with Title 14,CCR;Section 17041 etseq,should any member of the public re}uest disclosure of this information,I request that CIWMB <br /> contact me at the,jddress and telephone number above. *: <br /> I certify that under penalty of perjury under the laws of thq State of California that the informaiio!1provided above is true and correct.In addition,I am aware that falsification of this f-- <br /> information may result in civii penalties up to$75 0(p pe?'day,per viota0m or administ fv .penattieS up to$5,000 por violation per day wfiescribed in Public Resources Code <br /> section 42962 ! !. <br /> Ae resentative Name(print) .Represp ative's Signatu1e� : ...-- -=M,._..-Date 32876 <br /> ■ Toll Free 1-806 $96-0600 / www.ciwmb.ca.gov/Tires/ ■, <br /> While:CIWM'B-Copy Pink:Tre tNater.Generato*'End-Use Facility Copy Yelton:Hauler Copy <br /> y� <br /> FORM NO.M-104799-CUMS e12Y5m ffM;576649 - <br />