|
191Iplti, r'ti2Jv.0 -.-�T 4 _.,7t.1 .. •` -^ y.: rsJ - :�'.}-,�`T.' 4.' Y�!. Y.Kj, ice•„- :::5? £<-....:
<br /> I ,h. ,,Y ri:i :i•,fir,**; ' yya. ¥Q.�+ }, :-- ,d s y i s y Y y r
<br /> .:¢;;..I.t ,. e 1 yr• �E .y:.3` Fi?!4G7.SJL'!-mak.-�_•'.9 ��V�� ' V
<br /> W
<br /> '"f. s,.�*�.sv:-;•.J-,�,, •b [,�,. .a t.'.`.71. _ 'it-':L^ '£ - --_ �1V� r7F
<br /> t F'f°[ f. ,w I r')• Y o �'.j, ,^ � J '� 7iept fiiO,�p, me(1�gcy)fR,,j)a d'Aebbvd
<br /> f� � pr�eten` �e ' 1. °..'. ° i (tReeipts iooYor>ax;R269ts1famenng,E�938{3 12
<br /> �_ _ ��,��e��*�'��� •1.i2:e 51SI@dT#'i `1�L(rl�ber ,'::
<br /> .�'�!�iW�,I/f�'� •,�� M1 1•"f 1hl ` r < ,�.,�".'•_ ..:�a�,.���:1 r� �4{ L F r5 ��7j1C�tCsx� ` V rL.t��'. �c' "
<br /> � �.��'+•j� s � � �4iN"�;� +A�.� � FiT"2��1�b�1�1��fi�kR
<br /> •.)�i�� 'h�7�y�14�rd�,t11J+.QJ��r�1"1��h'fwn.�v1]}ip-Soy�n�gd i'p1,:a�`tOnPr�QitcgiN�I't�ieT�ylyS)Ilopndtlonb�Nd ;bri917�f6TinlYjrtMYebhrldfj{'daTdRnd:rVgif�'to�'fbfdryifj4�ddlp'iiU�e:dccu aner(v1�alAkrld-0G , �eU�lt
<br /> + s. fte7.ftr/�I�Aquie) iPpN►"MJ„dlsflPw.ws.Gil-IMm1VQH,�Gtalpjc}Iplr{v_ih Abn1.1`fhM�`pN I)pJjNfiPKll e�j
<br /> Ciu
<br /> p P pG 11'erpc8•jlQedbnAfil�b ut 2.1P1,}, r 3-.,. ,. >...
<br /> s r •" _ 31tC�,r I}i t Y r 1T�r'C-,Y'ST_'''''T-. ) r k .s 1 -
<br /> .�
<br /> �Us'nesslJame ,.
<br /> and.Z 0'_
<br /> kz
<br /> Common ff > `
<br /> Carrier
<br /> 3 J; 1 � .d
<br /> ^ ] •HJ�..,mQ•tp•npryol Q3tJ,-W-0lif•ffh•I�ws�gl iH.StLbof�dlydrr�4 t�}Ghi hJ nprovlaer}vboVa Je.lru0•rad br cL In•ddll4on,IsnLe "t•Ia1lAwfaAib ,�IWRIe M •ua ldf•VyPawotL=evoc•non,oT deNal Of referral nt_:'•.
<br /> �t• trl{i (•.'11it li7 flM(tlel ilYo(I,pumuml bP iilsdlie•'ityaf•'iibllon dzBbD :may rOrull In cytpurialli eup-to S2�000 pp1-Ylhy to ofadmin(i�te�iq penal�ts•II:+a fS Pih {ilgrr psMSy�m.d �Iad'In.P blldResowcai;
<br /> f C4 — 2
<br /> tk� e
<br /> STi 1 tE, .hi�t����Sx`'fiJ. . _ i_ _ tr �l�►�rs��dnaL 11 t �� �'i r .t.:DaYgt
<br /> k k J
<br /> 0.
<br /> I
<br /> L•°: 5752670v.
<br /> 'Hauler Tire Program~ID-,.J ''SIte-Suftfx, :Faculty Telephone Ntarriber..
<br /> :M'"• Yom/`
<br /> §� ;J Fa
<br /> t ` �iy,Tire tompany
<br /> z-�� r`,^.t � l•F o Namrne/Adlj s..;';:.:
<br /> io
<br /> :Hauler Namea � G1rrIS f4venue
<br /> Sacrom6nto, CR 95$3$
<br /> } 4 Stamp or Label QI<
<br /> l ` HaulerTe7epfiong-Number - Jr t �- .Q Address.Sameas:Hauler m'Isle-
<br /> 1Za ICERTIFYTyAT UN DER PENALTY OF PERJURY OF THE
<br /> '� ..' hath lie LAWS OF THE STATE OFrCAI.IFORNUI THATTHE
<br /> INFORMATION PROVIDED ABOVE
<br /> 13 TRUE AND COIIREC7.-
<br /> • • ,• •• • •.• • • •
<br /> It
<br /> 5
<br /> .5752 6 70 - ..........1.........�
<br /> 4 Jif 4+1
<br /> Hauler.Tire Program ID ;/ 'Sit• Suffix � �'�'� � QL
<br /> , .' ac��ity Telphori umber
<br /> 3-0 n DOE
<br /> ea
<br /> r f; {4,;x 1 �r FacilityB ines6'
<br /> 'w> Cy, i/g m� Vic} a� ��rVeigh>1WTolSsi Name/ dress,
<br /> si�1 n+v't' ,f. ,14 yr _.1 Cit {' ateatid LI)
<br /> ,o :-HaulerNaMe r• F ,,..�. :_ , I
<br /> S mp'o?Label OK
<br /> ^' t 'Hauler Tele .one Numbers �! `�,. l .Address Same as,Hauler m;uars
<br /> T'1 - y ate ¢'�y„' f3 t'tf. '1�"�r=� rFgg�fio /CERTIFY THAT UNDER PENALTY OF PERJURY OF THE
<br /> {3= •:�' g- T l it, t -1 :. ' 7 hOlq'14ifes�-?. ,LAWS OF TIIE'.STATE or CALIFORNIA THAT THE
<br /> '!. 'T+'1.=•'y ; , F�.i-.•I' >:eltilt•S',4}"1`,is •, INFORMA71ON PROVIDED ABOVE IS TRUE AND CORRECT.
<br /> 5752670 1`- Q �,� [ I, F�, �T;,.s `4 ,
<br /> }lauler The program ID / Srte,Suffix' Facility Telephone C�,yinber-
<br /> 1 t XaC},iiY s Q a1 SNl �V
<br /> Naialt?r.Nam '.' 1:` a I and '�r
<br /> Hauler:Tele hone Number ;gddfes Same a§Hauler
<br /> �ry Init)e/r
<br /> !•>Sl /�„�J 1 !- <<"c--1�':,J, „ 'J
<br /> ERTIFG'T A7 UNOER P.E�ALTY OF kER!(1RY OF THE ^
<br />
|