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<br /> I p y perjury under the laws of tha$tate of California that the inforn'teiion provided above is true
<br /> and correct. In addition,I aM aware That falsification of thig Information may resull in suepenslon,revocation,or denial
<br /> .Of renewal Of the Waste Tire Hauler Magletration pursuant to Public ROSOUTC09 COd6 section 42960 and may result in
<br /> Civil penalties up to$25,000 per tlay,per violation or administrative penalties up to s5.000 per violation per tlay as
<br /> descrbed'In Public Resources Code Section 42262.
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<br /> Driver's Name (prim) Driver's Signature Date
<br /> 23259
<br /> Toll Free 1-866-896-0600 /www.C1WMb.Ca.gov/Tires/
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