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b e Toll Free 1-,866-896,0600/ �vw�w clvl�rr�,�.ca.,�oy/Tires/ <br /> CA om rehensive T, `1 L.og and Receipts 1'0002 CP..0 BoxIM,S �►:Ine ro C�B95812'_z$ <br /> E X Ip (4, t11121:11 <br /> ! $ Com reh®n$Ive Tri Number <br /> aw►,eaa,�,nnq INSTRUCTIONS ON BACK OF PART 2 O NOT T E STAPLE OR LDUPLICATE <br /> BY elpnl.g rhle CA COmPFQII aI r•Trio Log and R•c•Ipt,"el9ner(q mgwt tMt ihs 1Marra•dao provided on dde Varm will be oonsIdarad canlld•ngal, ro rleL and tr <br /> 17041 et sep.,11•r«Iw•t la made for dl•clu•ur•of thla Infill n no.,,the CIWMB whl cant•ct the e1 m P P rY •de seoret.In•ccordanoe M71h 71U•,1e[GR,Soottan <br /> 9 rt•)ar a,l•form at Cta add—•nd%lophone numbs pmvm•d on MU fo.m o <br /> Hauler Address <br /> Business Name 'SIRE NOE.TK NC• <br /> 3 3 o Address 30900 San AntiPWO St. <br /> City, State and Zip -tj>I ward,CA 94544 <br /> I` ' ! � <br /> ❑ Common . <br /> „ artier <br /> I certXyulwer p•ntiity of penury under 0e la of Ihq Su`te,P(C•lifom1-that the In!c.,.�•tlon Provided above b true and aineq.In addlt I•m awaro Rtet felal6 <br /> i Weate Tire Heul•r RI ghnifon puro,mn)_to Public R•ao�rcea Cotle saeion�Z860 ane may Wp, crNon of thta Infolmetbn may ra•ult I <br /> y mutt In alvR P.-Wed M penellles u to$, r l auepe r ay rywxa or denim of alloUry o <br /> C440 eeatlsn A.2pe2 . W•Pee uD ra S X6,000 erday,P•r viol or adminl•tre0 <br /> �. � P ddadan Par day as deaulbl�atn public Rasot.rye <br /> river's-Signature Date <br /> 2 4 -- C <br /> Hauler Tire Program ID ffix ` Facility Telephone Number <br /> r>r I Facility Susiness i4ro <br /> Hauler Name tor"idA*ssCiti n*,� 4 P <br /> n <br /> Stamp or' <br /> Hauler Telephone Number 0 Address.Same r Iris _.J <br /> I CERTIFY THAT UNDER MALTY OF P"4URY OF <br /> �'t �'•t LAWS OF THE STAT•OF CALIFORNIA THAT THE <br /> IHFORMA. YID EIBr.7Y1 RpL7 <br /> { 4 8 5:5 ,,4 -iii }� <br /> Hauler Tiro Program ID / Site Suffix �, // Facility Telephone Number <br /> 1;0U H-PREPEPEc <br /> Facility BGsines ?arti� o r3 <br /> Name/Address lc1 t� � �,s� LP`c�,.;� <br /> Hauler Name City, State and Zip <br /> Stamp or`Label OK <br /> Hauler Telephone Number '' °'' Address Same'as Hauler <br /> ra <br /> I CERTIFY THAT"NOM PENALTY OF PERJURY OF TN! <br /> ✓�I �� /.> !!;2L_(1CAI LAWS OF THE STATE OF CALURORNU YNAT�THE <br /> INFORMAX I DED ABOVE 18 TRUE O <br /> • • ee <br /> e• • ORP7Q ©-� <br /> Hauler Tire Program 10 / Site u } �. Facility Telephone Number <br /> Facility <br /> Hauler blame City, State <br /> ISt-amp or Label OK <br /> r, Hauler Telephone Number I ( At)CfrPrxR fiarnr�via Harllnr <br /> VO 39dd d'd0'D HD S"V-d-11103 5ZLb6t`zG0z Z5-L0 800VOT/0t <br />