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SEP-10-2004 11 : 16 AM MIDAS. AUTO. SERVICE 2093699430 <br /> P. 05 <br /> . w�te.and Used, Fire Nianife Calttomle h>tq igtsd waste neanopement Board <br /> ,0[efmtenta CA ON12-1290 <br /> a• is 12 Wnber <br /> w`seotmei ns INSTRUCTIONS(W BACK 3 1 4 52= 1, 94 <br /> Hauler ;fr„.,.... •, _n,.,r,�cc�-sham ___..-^, _ <br /> ALL IMAGE TINLE fc WI L t <br /> 9003.CMMOVIICEELN.#t <br /> LODI,CA 95210 <br /> L4:!~ ("vs)M4M 1 <br /> F Iauler's Business Phone <br /> (Include area code) <br /> ! 1 <br /> Mahler ExeMption (11 applicable) <br /> ❑Government Q LEA @>iempt <br /> i Load Date(Mlwp YY) Log Number <br /> }} i]Agriculture [�Common Carrier/ <br /> Back Haul . <br /> IndIc8te.(If applicable)❑In Transit <br /> ! <br /> License Plate Number __ State Decal Number <br /> 0donfidentlelHy Claim:The information provided in Part I and Part It of this form should be considered confidential,propdptAry,and/or trade secret.In <br /> aCeardance-with Title 14,CCR,Section 19041 etseq,should any member of the public requeAt disclosure of this informatIon,I.request that C11A",contata <br /> me at the address and telephone number above. <br /> I certify that under penally(N perjury under the Iews of the Stale of California that the infonnalkin provided above Isle ane correct. Iri addMc;K,'f drA iiiiiii its Mel falelllcalfon of this <br /> informalion may rpsun in suspension•revocation,or denial of renewal of the Waste Tlru Hauler negialration pj�sim In Public Resourcee Co eeralon4213t10 and may rasuh In civil <br /> ipsnaltes4lp to$26.000 per day,-per violation or administrative penahies up to$,15.00d IMr violation per day as descried in Public Resources Code section 42962. M1 <br /> i <br /> Driver's Name rent Driver's Si nature Date ' <br /> 1• <br /> 170�ifional Address t,'aUel) — - <br /> __ _ <br /> Business Name Facility'&IIcfiide at411”do) <br /> l 1 _1._.__,.i_._.:'.:.,'__.. __.t'..... 1 1__.1 <br /> Number&Street Address <br /> /_ .p aaanw slkne n�wearer <br /> r k C ❑change Of Address <br /> L �I L .._l.. .l._. 1 1 1_..._____._: !_-L__.; <br /> i City Stat@ ZIP Code <br /> I - Tire Types and Amounts Intended Use <br /> A j ❑Passenger Oversize.. ...._.—, .-- 0 ❑Retread/Reuse <br /> llT��iir__e-Program ID Site Suffix j t f I I <br /> ' ; ! � ❑Rocyele <br /> ❑Truck Other ❑Fuel <br /> " <br /> I. epOeeUlatldfill <br /> J_ ❑ <br /> Ir <br /> Comment Area <br /> s. <br /> OConfidentiality Claim:The Information provided in Part I and Part It of this form should be considered confldendalrproprialevy,'and/ortrade secret. <br /> In accordance with Title 14,CCF,Section 17041 el.seq,should any member of the public request diWocure of this InformattaR.t request that GIWNg3 <br /> contact me at the address and telephone number above. <br /> I certify that under penalty of perjury under the laws o1 the state of Catltornis thal IN Information provided above Is true and oonep•In adds ort,l WP .11stla18IflCation 01 this <br /> infoematbn may result In civil penalties up to$25,000 per day,per violation or aunlinlMrative penalties up to$s.000 per violation per dayari gescri ed in,Rtl tic Resources Code <br /> secllon 42982. JJ y <br /> " <br /> Date' <br /> Representative Name(print)' Representative's S1 nature328 <br /> . , <br /> Toll Free 1-866-896-0600 / www.Ciwmb.Ca:Vovli•irew =: <br /> White:CIWM9 Copy Pink:Tire OeatertGoneraror/End•UQe Facitity 000v Yellow:Hauler Copy <br /> 1'0nM Nn M 10'174-CIWMB yNO <br /> __ w <br />