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630 (New 4/03) Page 2 of 2 <br />P9911620:0214010, <br />I certify under penalty of perjury under the laws of the State of California that the inforrnnation on this <br />avolication is true and correct <br />�"S' of Authorized Agent Date <br />c�mL T6-",QtAA PGC�� <br />Printed Name of Authorized Agent Title of Authorized Agent <br />M, cais (1 1� r rr ai :. r .77'+ + <br />P.O. <br />Sacramento, e95812-4025 <br />FAX (916) a,, <br />Additional Address Entries for Qfisite Waste Tire locations: <br />�i City: State: 23P Code: <br />Business Ad s icaall <br />Ci $ ZIP <br />A• , <br />q <br />DMIMMr , <br />-City: State: III'Code: <br />{� • d XUJ 13rN3SUI dH WdSZ : t T 5002 BI 2nU <br />