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12/30/2014 01 :50 IFAX isacramf aeastbaytire. com Dianne Amaral 1 008/015 <br /> Toll Free 1-866-896-0600 / www.calrepXCle.ca.g.ovM=/ <br /> 111 Dept.of R•eduro••R•oyollnp and R•aavery <br /> Comprehensive Trip Lag and Receipts 10002 Po r1ox1250,Seuemento,CA25812-Mg <br /> Calle X M P E 1 Corn rehensive Trig)Number <br /> 9100 9(w <br /> satae91ue2074INSTRUCTIONS ON BACK OF PART 2DO <br /> ey ei9n(ng tt)Ij OA Oomprah.n.M Trip Lop and Malpt,Ih•.Ignw(l r.gw.1 that the InfOrmaden prmIded On E14 forts WI11 be amald9rsd oonlld.nd.i,praprfatery and trod.aearel.In...Id....with Thie,1e OCR.6eallen <br /> IT041 stand„E.mgw.t{.meas Icr al.cloawm W thle IntOltnatlon.CAIReeyole wIl[oonleatttla nrpnwle)Of Ihle to"*I 1ha.a.dm12 and tN.phon•number pto�1400 on thlo fan.ar-..WPL <br /> Hauler Address <br /> Business Name F Ec15t Boy Tire Company <br /> d s Address <br /> City,State and Zip 2200 Huntington Dr <br /> 4 s 7 A-- 0 r teaon L. Fairfield, CA 94533 J <br /> I panlN untl.r prub of psrL+y under tflq 40'0 of Ih WO4 of G.uf—l.M.I.Ina information pmwded abo**t0 true and cOtn01,In g4dlUan,I am aware that f.l•IRcNbn uf two lnfa marton may Hoer In auspsnnon,nwovetlon.of dlntlel 0f tM Wml et <br /> Iha Wa.m Tim Haider R4didrallon pum.ht to Publk RwW res.Cede..orlon 42080 and may=U11 In OMI 156081144 Up t0 B 96.000 Dor day.per vlolallon w adminhlNUW 040114"uo ra 115,000 pw ylolatlon par 1 ee/gp�nU1"dd In M11C pqs�'-. <br /> Cotln uallon 4298 / <br /> Driver's Name rin Iver'e, tore . - �h pLlete <br /> 847894 , -- C X, <br /> Hauler Tire Program-11) f Site Suffix Feeility Telephone Number <br /> Facility W Tim (`OMPOnV <br /> In Q lol �rll I Name/Adh8"QrrlS rjVen <br /> City, ��aann��7�p U0 <br /> Hauler Name `��r►111L17, CEA 95838 <br /> tj� ! Stamp or Label OK <br /> Hauler Telephone Numkfer L] AddressSame•ae Hauler <br /> I CERAW&FY THAT TATER CAUP Y OF THAT TMFINURY THE <br /> LAWi OF THL STATE OF CALIPORNIq THAT THE <br /> 94FORMAT1oH PROVIDED A00Ve II TRUE ANDT <br /> e • <br /> 4847894 -- B - <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> oo- ao� aoao <br /> a t . <br /> =� acility Business <br /> Name/Address <br /> City, State and Zip <br /> Hauler Name <br /> Stamp or Label OK <br /> Hauler Telephone Number 0 Address Same as Hauler <br /> —] <br /> r I CERTIFY THAT kINaFR PENALTY OF PERJURY OFTHff <br /> L' LAW9 OP THE STATE OP CALIFORNIA THAT THE <br /> INFORMAT<ON PROVIDW AROVE IS TWI AND 009 <br /> • <br /> 4847894 W- 11. X. <br /> ,t�t <br /> Hauler Tiro ftgrem-10 'el" x: a ;d`Mttrnbl3r <br /> ruti'ait!r-i: :: .r -,)b?) nU i i i� <br /> a0i'.1ct;�}�f�:t..1'la�:i'��e1 LR�r�t)`la C tEi t 4Ei4!) <br /> Hauler WiifiW <br /> ':1sfl l'.t1L1,',t41'rt'>� 1\�",_T'_4:,�_s;i�A:�'!:%7 i� 'f: �� Y3': 'C,c1' � :i �x"Olq � �aY��vJn•,",r-i e., <br /> Hou#i i�leph'oiie,=Nutrer <br /> .�^ .. 'a + rri� i'dYdlrwrt1Y�'v.a.u. <br />