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State of California Department of Resources Recycling and Recovery (CalRecycle) <br /> CalRecycle 811 (Rev. 1/16) <br /> Waste Tire Facility Permit Exclusion Notification <br /> Business and Property Ownership Information <br /> Note:This form will be rejected if any required information(marked by an asterisk*)is missing or Illegible. This information is <br /> being requested in accordance with state regulations. The information is required and will only be used by CalRecycle. <br /> C� <br /> Tire Program Identification (TPID) # J702-9 b(v <br /> �'� \ l`-'�?�,)C�. ili2c �t�Z��ci.,L.�v►-1�Q �.,�c... �\- � �',�cn — `� ��ti� <br /> Business ome ' Business Hours of Operation " <br /> l <br /> As Aoc j <br /> Business Owner/Operator Name ' Property Owner Nome ' <br /> 10 -7'0 ?- -1 0 o <br /> Business Street Address ' Property Assessor Parcel Number and County <br /> I-�e►�Cl,� ( r�� i CA i q5-L_31 Vkv_7 (_�:r\e_ Ru',\ A-V£ <br /> City,State,ZiP Code * Property Owner Mailing Address ' <br /> A <br /> Bus11iness Mailing Address( ❑ some as street address) " City,State,Zip Code " <br /> U1u(l.C5io (St" Q s (26 ) <br /> City,State,Zip Code ' Property Owner Phone Number <br /> (26A) <br /> Business Phone NumberBusiness Email Address <br /> OperationBusiness <br /> This business qualifies for a waste tire permit exclusion based on the following authority: <br /> ❑ Agricultural Purposes (PRC sections 42831,42801 and 14 CCR, section 18420) <br /> 0 Tire Treading Business (PRC section 42831 and 14 CCR, section 18420) <br /> ❑ Automobile Dismantler (PRC section 42808 and 14 CCR, section 18420) <br /> Tire Dealer(PRC section 42808(c) and 14 CCR, section 17225.820) <br /> ❑ Waste Tire Collection Location (14 CCR, Section 18420.1) ,�► ,, <br /> What is the average quantity of waste tires this business handles on an annual basis?* aTc)V <br /> Business Description* Si�� tp SFn_V'Cz G� <br /> Certification <br /> 'By signing below, I hereby certify under penalty of perjury that this waste tire facility complies with all required <br /> permits, licenses, and other local approvals, and that the information provided in this document is true and correct to <br /> the best of my knowledge and belief. <br /> Fa <br /> 11 ility Oper or A nt Printed Name Title <br /> * F ility Operator or Age gnature Date <br /> Submit by e-mail to:WasteTires(@CalRecvcle.ca.eov <br /> Submit by Fax to:916-319-7605 January 19, 2016 <br />