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State of California Department of Resources Recycling and Recovery (CalRecycle) <br /> CalRecycle 811 (New 11/14) <br /> Waste Tire Facility Permit Exclusion Notification <br /> TPID # 1�� � I`e-ib <br /> —o ( <br /> Business and Property <br /> Business None Business Hours of Operation f <br /> Le <br /> Busing s D ncr/Operator Name Property Owner <br /> \1 F <br /> rev <br /> Business Street Address Property Assessor Parcel Number <br /> ivy c <br /> City, State, ZIP Code Property Owner Mailing Address <br /> Business Mailing Address City,Stotc,lip Code <br /> City, State, Zip Code /� Property Owner Phone Number <br /> r, �v <br /> Business Phone Number Business Emoil Address <br /> Business Operation i y i <br /> This information is being requested in accordance with state regulations. The information is required and will only be used <br /> by CalRecycle. <br /> 'rhis business qualifies for a permit exclusion based on the following: <br /> ❑ Agricultural Purposes (PRC sections 42831, 42801 and 14 CCR, section 18420) <br /> ❑ Tire Treading Business (PRC section 42831 and 14 CCR, section 184.20) <br /> ❑ Automobile Dismantler (PRC section 42808 and 14 CCR, section 18420) <br /> IrY Tire Dealer (PRC section 42808(c) and 14 CCR, section 17225.820) <br /> ❑ Waste Tire Collection location (14 CCR, Section 184.20.1) <br /> What is the average quantity of waste tires this business handles on an annual basis? <br /> Business Description L^Jl �( _�' dL <br /> By signing below, i certify under penolty of perjury that this waste tiro facility complies with all required <br /> permits, licenses, and other local approvals, i certify under penalty of perjury that the information provided in <br /> this document is true and correct to the best of my knowledge and belief. <br /> -- ^U Fa'i ' perms Agent'Pr.�ted Name Title <br /> Facility Operitar or Agent Signature Date <br /> Subrnit�bl e mall:Waste7ires@CalRecycle.ca.gov Submit by Fax: 916-319-7605 <br /> March 24, 2015 <br />