|
AUG 3.2005. 8 33AM TRI—C TIRE N0.065 P.2i3
<br /> ',�' .r` •:'• �'' � .• . . ' ' i '�,ilfOrnl21 trtfp�w�d'l�sete Ivlartagament
<br /> o: ir �c tt ', .' � 'r�'' �� a�i,sox7asa::.sai.r,ty c� � •
<br /> ,t:', C %F N1'B .-L' f` .2, -3 �Ianast Nium6ar
<br /> 401
<br /> 84W INS . t
<br /> uler.
<br /> rr.f (ft raTf-A•rd,m'Mss
<br /> e
<br /> T.. GPOIC
<br /> ;4►ddress Sa&'ttmeiio'CA 9S.&28
<br /> Malu(ere'"iness Phone
<br /> ('Qtcidde 41M' i ode) t
<br /> Hagler kxeritption (lf applicable)
<br /> +t ' - ,1. w , '`-•i. �,, + - ; a Goveiem Cl L =a4.Exempt
<br /> Lob, 'Date-,(M�nror3mr} lag Number, ]AOricuftura (3Common Carrier/
<br /> Back Haul '
<br /> �; � . .
<br /> _ tndicate(ffi,apprate)D it,Transit
<br /> 706d
<br /> tMait II ofthisfor should,pbponslq$ffe .40i� nt�at,prop�latary,antllor trach secar4t I'n
<br /> ��Re !�tl1l itlfdtt tipti,:f YeQgt th #,eMI1A(AA8 cont�atdc �ander enaltof erfuuntfer the taws of the State of t�Iifp(nla Ihatlhe intomwdat� tied t{bove istrge atilt oorraot. In•addldon,14M aware that fal�fk,ation of this.
<br /> aTirel1avler Purrs U9 Public Resod�o!s Ct+dy olv42W end may gull it duff to P�daY,Per Wole}ton qr adlnlntstrurve pertetlt;taa yp to$5,000
<br /> Por of dasc►lb9d in Publ►o�Ieeouroes Cod tel 42se2•
<br /> FP60
<br /> nal-AAMWs Labbl)
<br /> `d .C7�
<br /> S.usiness Game Facliw-s 911us/!Hess Pharle(include area code)
<br /> Number&'Street,Itddres$
<br /> 0 Addreaa,ame,As Mauler
<br /> Change 4f Address
<br /> city _ztde
<br /> Tire Types and Amounts Intended Use,
<br /> L , I L7 Papseng®r ' ❑oveNze ❑Retread/Reuse
<br /> Tire.Prograrit ID' Sita'Suf x •m ❑faecyrcle
<br /> Q Tn* f]fitter [ FuOt
<br /> v, 1
<br /> TF
<br /> l Q CiepgstsVlandfin
<br /> C cimi neat Ar6a
<br /> pcorifidentiality Craiin:The info r Cation provided:fn PsI aM?art II'of this Corm should'beconsidered-t mfidential,proprietary„and/agrtrade secret.
<br /> In acoorpance vfitft'Tttle 14,CC9,Secdon,x7041 et.seq,should.any memberof the public request disciosvre of this ipfarrnation,.I request that CIWMB.
<br /> contact me at the address and,telephone numWr above-
<br /> i cel itytnet under peachy of,periury t nderthefaws et,tho Stateof Celiforgs slw:r. ballon PW09d above is true.and oweet,In addition.I am aware that;aWication of this
<br /> i�omwior may result in oMI Waitfee up to$28;000 per day,per vfotation or,adm f ve per
<br /> up to$5,QM per vlelation per day as destxibad in Public Resources Code
<br /> Gabon 42982.. ;r
<br /> Representative Name(point) �.r *,Repre$enteii $'S.ftneture Date 92876
<br /> Tot f.Free•1-866-69.6«0'600 / v-ww.ciw Mb.ca.9bV/1 i reS/ f
<br />
|