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CIWMB 690(New 4/03) Page 2 of 2 <br /> Please sign application <br /> I certify under penalty of perjury under the laws of the State of California that the information on this <br /> application is true and correct. <br /> Signature of Authorized Agent Date <br /> Printed Name of Authorized Agent Title of Authorized Agent <br /> Submit your TPID Number application to: <br /> CIWMB <br /> Waste Tire Hauler Program,MS-22 <br /> P.O. Box 4025 <br /> Sacramento, CA 95812-4025 <br /> FAX(916)319-7605 <br /> Additional Address Entries for Offsite Waste Tire locations: <br /> Business Address (Physical location): <br /> Cit State: ZIP Code: <br /> Business Address (Physical location): <br /> city: State: ZIP Code: <br /> Business Address (Physical location): <br /> city: State: ZIP Code: <br /> Business Address (Physical location): <br /> city: State: ZIP Code: <br /> Business Address (Physical location): <br /> City: State: ZIP Code: <br />