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0 <br /> M" rr ,i, ',. ••,n. �^ �' �„ � :(4.h 'Si r. ,y. i i�''. ���'��'f Pa � '�i zr%':i"�rr.'.. .x +4 <br /> s sl <br /> CA UnNorrn Wants. and Used Tim an `Po aIntegrated 2Sacramento,CA"96a;`�`2 <br /> EXAMPLE 1 2 3 Manliest Number <br /> erataetcaaromr INSTRUCTIONS ON Bt� AACK ILII I - 1-2.4. 7 6 8 9 <br /> M. OMP.L. Aw "Rit f A' X"iatiea pliAt) _ _.... <br /> ❑Import from <br /> (1'outside California Stste/Country)a <br /> '❑Delivery <br /> ❑Export to <br /> IHauler's 6Jslness Phone <br /> 4 (If ou side allfar�fa atdlCddrAry) (Include area code) ( �b ) Q t Aj G (a 2— <br /> Hauler Exemption (if applicable} <br /> ! © 1 ❑ Government ❑ LEA Exempt <br /> Load Dete (MrwroofYY) fff Log Number ❑Agrc,,lture ❑ Commor Carr ori <br /> Beck Haul <br /> 0 '�4 ( Indicate(n appll0able)0I Transit <br /> License Ii Number State Decal Number <br /> OConfldentiality Claim;The Information provided Ir Part I and Part II of this form should be considered confidential,proprietary,andtor vele secret. In <br /> accordance twth Title 14,CCR,Section 17041 et.seq,should any member of the public request disclosure of thle information, I request that CIWMB contact <br /> me at the address end telephone numb@,above. <br /> I certify trtat under penalty Of perjury under the laws of the State of California that the Informatfo ed a rd collect. d tion, em ewers that rats flaacan of this <br /> information r^ay result in euepens or revocation or derlal of-enewal or the W eels Tire Ha r Roglstr purouant to Ree ^ e Code aqction 42980 and may resu'I In C vll <br /> peneftea up to 625,000 per day.per Acla0an or acimin,atrative Wallies up to$3,000 per v' l p escroed P lic R reel CO eaerron 42962. <br /> .,.. <br /> d <br /> Driver's rent Ply r a S I .t to <br /> T­ COM] $ <br /> UaePko IIR_ <br /> FACILITY(pleat.ptnV$E ACNL-146010" <br /> Vp THE, [IR-Oii'DFtOPP O r <br /> Business Name Facility's Suallnsiss Phone(include area code) <br /> Number A Street Address <br /> Address Same AA me,lar <br /> a-3 ❑Charge OrAddreae <br /> ry \1 � State Zip Code <br /> Tire Types and Amounts Intended Use <br /> ^ �] 1 - ❑ Passenger ❑ OvereVae read/Reuse <br /> T re rogram ID 2� Site Suffix <br /> Recycle <br /> I L T"in lt(dwic-anh4*14) ruck ❑Other [ Fuel <br /> QWhi Tlrs Cownt 0,W0191it In.0104. l <br /> ❑valuate Clibk Yards C3W4110111n.TOniv ❑DisposeliAndflil <br /> Load Amount Comment Area <br /> ❑Conf Identiality Claim:The Information pravtded In pan 1 and Pa-t a of(hls form should be considered confidential,proprietary,andlor trade secret. <br /> in accordance with Title 14,CCR,Section 1,7041 et-seq,should any member of the public request disclosure of this Intcrmatlon,I request that CIWMB <br /> contact me at the address and telephone number above. <br /> I certify Chet under penalty of per(urj under the Tawe of the Slate of California that the Information provided above Is true and correct.I cd+tlon.I am ewers that fdtiticatlon of this <br /> information may nsuli In civil peneitiss up to$25,000 per day,per violation or administrative penalties up to$5,000 per vii y as described In Public Resources Code <br /> section 42982. <br /> Representative AaMS(print) R ipeCelintatly Signature Date 32878 <br /> Toll Free 1-866-896-0600 / www.clwmb.ca.gov/Tires/ <br /> B 'd oeee 13CN3SU-1 JH WdbZ t Z T 9002 LO UeC <br />