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s <br />State of Callfornla—Health and Welfare <br />Agency <br />Department of Health Services <br />Toxic Substances Control Division <br />714/744 P Street <br />APPLICATION FOR VEHICLE/CONTAINER INSPECTION Sacramento. CA 95014 <br />Firm <br /><1��i5'�.C�V <br />r <br />Nams -- ! �/N <br />vz =,� c <br />�® /✓� Contact Person /// <br />Inspection Address <br />J�- <br />Mailing Address o ® X <br />s/ere.c <br />"�7`, <br />cit zip <br />S� <br />/fP <br />EPA `— � q �9 <br />o BOX/Street <br />7 37,?.� 5� <br />yL�U�9 <br />City Zip <br />ID No. / <br />LIST VEHICLES AND CONTAINERS USED TO HAUL HAZARDOUS <br />WASTES <br />(See instructions on back of this form.) <br />_ <br />Hauler Registration No. .(i 7 - <br />Inspection Few <br />Vehicle — $fi0 <br />Container—$50 <br />YearCHP <br />and <br />and <br />Lioarw Plate Number <br />or <br />Container Number <br />'Body Type <br />DHS <br />Use <br />Use Only <br />Certificate <br />Certification <br />Only <br />Number <br />Date <br />Specification <br />q p <br />/ <br />e <br />.ilUI 1%i 17ED <br />at's <br />$ �v®� TOT <br />C\ („ n' n n � Ich Services.) 9� <br />C(CATION <br />I certify under penalty elief the vehicle(s) and container(s) described above conform to <br />the requirements of Se ode. <br />Typed or Printed Name �v �/ �� <br />Position Oateto <br />Y <br />RECOMMENDATION Revocation ❑ Other ❑ <br />on) (Renewal) <br />TERMINAL: 10 Not Evaluated ❑ <br />REMARKS: I <br />Signature 10 Number <br />Division Date <br />DHS 8025 (12/85) <br />