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<br /> �xCalifomia Integrated Waste Management Unfc�rm�:�Afa�.t�.e and Vs�d �'ir� .IIAar�ifest 9 9 ent Board ■
<br /> r PO Box,i? g Sat ramento,CA 95812-1259
<br /> ?G A M F �. E ]" 2 .3 - Mabffest Number' AQ
<br /> State of California ,e Z 0. 3. 7 M - -
<br /> ciwMr +7(osro3) INSTRUCTIONS OH.BACff MMM
<br /> i
<br /> (rip et. Address-L Abet ..
<br /> 7]-' 1
<br /> Business Na (JOt "AY �_
<br /> City,; State,Zip
<br /> auler's Business Phone
<br /> (include.area code)
<br /> ` 'Hauler Exetnptfan ( applicable)"
<br /> r
<br /> ` Gov6rrimenf.l LEA Exempt
<br /> Load Date (MM/D[)/vv) Lo§Number ;
<br /> Q Agrlcuiture' El•Cornmon Carrier/
<br /> pack pavl,
<br /> indicate(ite P1icablaI.O.in Transit -
<br /> License Plate Number State " Decal'Number
<br /> QConfidentiality Claim:The information provide 4in Part I and Part II of this form shouldfce considered confidential,,p[aprigta'ry,and/pr trade secret In
<br /> accordance with Title 14,-CCR,:Sectlon 44l etseg should any mgrnPer ofjhe pt b!lc request d�sGlo"soca cf Ibis rnfprmattrrrt j request that-GIWMB contact
<br /> me'at-tbe;address and'terephorttieittttte� atir�ve a :a
<br /> s _ „
<br /> I cenffy.that urider'penaltybf priqury.pnder th6.livr� otiihe�Yate-of Ealifornla'ik}At'the informal+ort provided'abtive is tri�e`'and correct. Irl addition,f aril ewaie that ialsi icatiarFdflhi�
<br /> information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant•toPublic Resouroes'Code section 42966 andmay 6duff in civil
<br /> penalties up to,,$ 5,000 per day,per violation or acirpinistrative penalties'up,to•$5,Obo,p.er vidlatibn po kAday as described in Public Resources£ode Se, iar+,4B9621�
<br /> AZ
<br /> Driver's Name(print) 's Signature Date
<br /> (optional-,4ctfress Label]
<br /> Business Name` Ft#ctli1y's Bus'llieSs PllOfii ei lcluddarea code)
<br /> Number S#feet ddress f. ..
<br /> _ a Address Same As Hauler
<br /> i.! rj }T El.Change Of Address
<br /> 9� C_"�_X1.-._ t_ _J_- 1
<br /> ,�.,».�... • - ,.,-_-.�.,�..,, . � __. .State•.. . -Zi -CfSde. -
<br /> .�Tire Types and Amounts Intended Use
<br /> ❑ Passenger -Oversize. ::.p Retread/Reuse
<br /> Tire Program aD 5ite Suffix' 1"', j .....
<br /> -Recycle
<br /> ruck
<br /> #3' tF-
<br /> ee, gisposallLandfill
<br /> �y i
<br /> OConfidentiality Claim: The information provided.in.-Part l and.Palrt II.of this form!should becorisidered confidential,propr)etary;.and/or.tt'ade secret
<br /> in accordance with Title 14,CCR,Section 170417:et.segi stiUtildiarty.rllerrFher of:tlig,.publiG raguest disclpspre of Ois.inforrnation;I request;that CIWMB
<br /> Contact me at the aStdress-and telephone,numper.above.. -
<br /> a- _
<br /> I certify that under penalty of perjury under_the laws of the Slate of Catifomia that thQ infarmatinr prQv_irfedg4oye'iq true and eo{recf,,lR addition„I-am.aware that fatsiiicatign of-this
<br /> information may result in,civil,p�naltf es upito$25,QQQ per clay,per y olatioq o,-,dmiplstrative penalties.up to$S;Q00 per violat!on,per day as described.in Public Resources.Cade
<br /> section 42952. �-
<br /> Z41—
<br /> Re resPep
<br /> :p 9 .-... ^;;;bate'
<br /> p entatirie'Nanie(print) Re resentatIVe's.S% 'n-fore `: . 3287&
<br /> Toll Free 1-866Y96-40600.1 www chymb,ca. 9 ov,ITi eq/ 40
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