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Dec 16 2004 4i54PM HP LASERJEr 3330 P. 2
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<br /> CA Uniform Waste and Used Tire Manifest y4ai`a Awogornon!6ost
<br /> 10 8wL 1269, Stlaral-I CA 9591$• 269
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<br /> ' 'XjAjMIPJL�Ej M1 .2 3 Maniffost Number
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<br /> .W16110-441(03103) INSTRUCTIONS ON BACK
<br /> 5 4 0 0 1
<br /> PART 1: To BE COMPL9T-*0 SY TIPP.HAUL
<br /> PICK Up
<br /> 7 Import froir
<br /> (If CW7-0;tak orrda—5tawch6'.
<br /> bellvery On'
<br /> 7 Export to
<br /> i Hauler's SAliess Phone
<br /> (i-lu0s area code)
<br /> / 0 1 S Hauler Exemption (it OPP[Cabla)
<br /> Load Date IrArjj::D/yy± Log Number U Government 17 LEA Ewrpi
<br /> Agriculture U Corr"in Carrier/
<br /> Back Hau�
<br /> O� b 0 C I ndleate(1,1 appilcoole,0 fr Trans t
<br /> License Plato Number State Decal Number
<br /> 7COnfideritiolity Clalm. Tha information prMidav in Part I ard Port rl of thlo forrr 91"OWd be Confild8red cont1donflel,proprietary,and/or trade secret, q
<br /> 20cardarce wO Tititi 14,COR.Section 17041 ol.seq,should 00y member of tl�.a public reqt-106--diac:cgufe of This ri.formatlon,I request Ji,-at CIW,�jq=11140
<br /> Ino at the address and te,ephone rurrbbr above.
<br /> VIVY that urlae?penalty M pe,jury i,ndsr,.he lam or;hs Simla al oweorpla Iret tha I We Is U4 d in swro, I am awo that la*f callom of Into
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<br /> Informer on rnay resun in ajalper4oii,roycealar,�,r�tnlal e �Vj"R, I J�tj
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<br /> 08'10085 LP NO W.000per day,per yluation or administrative oaria,tiea-,jp to.$i,000 per vlgl&l on Is I In 0111111:01`1 P 41 OUrceis Code slot on 4N62,
<br /> Driver's NaMe(priw) Dr ers Shin—a
<br /> 'IV OP It IRE�0
<br /> PARTII: TO SE,COMPLETr;D:ey,f;Ep;q"tski'4i.' ' V."�L k WAt.-+-E:tI ftt'.o
<br /> A A ENSIPATOR OR SND-USE
<br /> FACILITY(Please print)-USE ACTUAL LOCATION.W.HgRIE THE TIRESAR.E.-PICKED-UP().R DROPPrzt)OFF.
<br /> 73-
<br /> Busliriess Name
<br /> Facility's Business Phone (include areato s3;
<br /> Number&Street Address
<br /> C:t Address Sarno As HILIell
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<br /> City slate Zip Cods,
<br /> Tire Types and Arriounts
<br /> intend d Use
<br /> 'tre,
<br /> Tire Progrerrit ID site ufflx
<br /> Load Type(checv an�y one c fuck ❑�Oth®r Whole Tro'CievnI I Wolght-in Rourl#' Fuel
<br /> VcLinaZubic Yards vVell;lhi in Tomi c
<br /> L-wo rap-�-.'%artd'ill
<br /> Load Amouht Comment Area
<br /> ElConlidentiallty C14IM:-he inforr,aii.cn provided In Part ' and Fart 11 cl this form should be romaldered:crifidontlaj,proprietary,aritfor,,rads,avcrw,
<br /> In acco"dirce wir Title 14,Con, Setlor 17041 61.6eq,should any rnernoer of the PJbl:C FO;Mt disclOSUre of%s Inforrratiom,I request the-awkis
<br /> contact rre at rhe acitreva and t4lsp1v=e ramber&Wvo.
<br /> C010,'%hstl awsof ft Sja;e of Calliforniia Chet;ha Wormatlan prurj!ded soove is IfUs SIC GOn"t &wition,19^I aware 111c 415ifluallon of IM
<br /> dormer or may requrin W1,11 nertait,!39 up t�826,000 per day,;er up It$5,000po(vole Dn par da)artdwribecl in Pubk Zwcat crxe
<br /> gre on 42962.
<br /> Represeritative Narne(print) Representative's Slqr.atu re Date 32878
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