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Jdrl-40-dU19 .tx:40 /Am U&IKeC„ -ildSLe I-ire muter y10.54103VU Ile <br /> Surto of 60(ReCaliforniaDepartment of Ratiources Recycyling and Recover(CatRecyclo) <br /> CaSRooyalo 40(Rev.x110) P.O.Box 4026.Swumento,CA 85812-4028 <br /> APPLICANT:This applioatlon to a: 7 <br /> CalRecycia Use Only 7hX-d6J;3T38 <br /> NewAPpiioatlon i] Change in Business Nama,Owner orValilcla Ownership ❑ lam/ <br /> Renewal 0 Change In Facility Address,Malttnp Address or Phone ❑ Reviewed 8 <br /> AddiDolato Vehicle t3 Raplaoarnant Dacwl <br /> Hate tS3Ued',' �• <br /> @Abash► Fire &mauler Registration Applicatlon <br /> Pursuant to Section 42960 al seq.of tiw public Resourcea Code,a waste tfra hauler shalt submit the following informetion on this form In order to obtain <br /> a Waste The Hauler Rogtitration and approval to transport used of wasta tires, <br /> APPlJCAN7%C046AB Z(TYPE OR PRiNT 1N INX)rTEMS f THROCJQH 17,1E A SPECIFIC i7FA4 ODES NOTAPPLY TO YOUR COMPANY ENTER <br /> "N/A",FOR NOT APFLIGA6LE. 1NCOMPI E/E OR PNOTOOOPfED FORMS MAY BE R&ECTED. <br /> 1.Name of Business*:Xavier%quality Tires <br /> 2.Ploasrs chsc{(the appropriate box for ft Business listad above: <br /> O individualf(Sole Proprietorship 0 Urnfted LiabfGty Company❑Corporation D PoWcal Subdivision <br /> 3. Facility address (The lacati0n of tho business indudtng whera vehicles and usod or waste tlroa ara stored): <br /> Street: 907 W Yosemite Ave <br /> City: Manteca State:CA Zip Code:86357 <br /> 4. Business Owner.Manule 8 Phone Number.(22W)923.4877 <br /> Social Security Number" SSN on File A DrIvar Lkona/ldsntiffcation Number <br /> r <br /> es ►>;Q t <br /> 5. 8uGimaManager(HdiffarentfromBustrimOwnw):' N i Phone Number.' <br /> 6. Other business names of the oompany(DBA'e): � <br /> T. Mailing address of company:097 W Yosemiba Ave <br /> City.Manteca State:CA Zip Code:95337 <br /> 8. Attach proal of bond(Form CIWMB-81), <br /> 9. Havq yo at any tlme had a fiean6a,permit,or registration issued by the D%mrtmeni that was the subject of a diseiplfnary action? <br /> ❑Yesp 0 if yes,please explain: <br /> 10.I understand that any misstatement or orrfasion Of material fact on this application shall be cause for punitive action or may be grounds for criminal, <br /> oMl,or administration actions,inciudtng denial,revocation,or auaponolon of the Warta tire hauler rogtstration,i cer8fy under penalty of perjury under <br /> the taws of th titate of C om)a that th Information on this application form Is true and correct: <br /> ignsture o ted geM labs ---T�� <br /> Printed Name of Authorized Agenta ut or`�A t <br /> >3sr+ <br /> `Name ofLrdividual,sole pmprlstorship,oo-partoar6h1p,limited t4WIy Company,corporation,or political subdMsion applying forregfstratlon. <br /> "Punivant to Faml(y Code Section 17920(d),persons applying for issuance or rune val of any lk;WISe or other authorization to engnga In a business, <br /> occupstlorn,or profession under any of tris iews admInistared by the Depertmero,must provide thetr social securely nurnbarfl to the Department bU The <br /> Department uses this Information to match their names to the norneg on the I(et pmvidod by the Department of Child Support Same.and to respond to <br /> requests far information made by shad support agenoiea. <br /> No reaislratton application fee is rmquirod.Inoomploto applications will be retuned and appiloant wail not be oonaidered ragtatered. <br /> RETURN COMPLETE REGISTRATION APPLICATION TO: Tire Hauler Compliance unit <br /> Waste Permitting,Compliance and h4it)gatidn Division <br /> Department Of Resouroas Recycling and Reoavery(CalRaoycle) <br /> D 2 1 if7 P.O.15ox <br /> mento <br /> L� U 8. <br /> 6eorsmvnto,CC <br /> A 95812.4026 <br /> JAN 2 8 2014 <br /> 13y <br />