|
e+-. •''�^" .,2D.� r.�.p; Ft}:SS S.w"NA"'I
<br /> -i� f-.';�':...:ii•.:y: _
<br /> Y= '`cF` r/...:aa.;.:._•��....Aa�f a{...so 16.06.t�9 n ac4�!'•.,
<br /> as c ,�� '% 'is•�'_ f°ra•.��e;{�r, :!. }1 .
<br /> je!0rik26 Sa Al- `a' ':` r.,e�. .�sive;Tri'�t�l•umger-ri::
<br /> '�'�y ',i. - '•t. � ..,:.,dl,,k,,:� A,t :sfaa..•rl: 'Rr`1':f iii.,:t;.
<br /> P.
<br /> ',"eis; .rcmA,� :�"• N'� B CKOF PARC _t)�;N01 TACE ST14RLlOR D�IPLIC;41'1=
<br /> ' ••sv '�i..t
<br /> e:'%r:�?t:"I nfn ICl\•Coln u�d•I�_T"1r8D'sNil'�fefll 1,Ili'Ylaner(:)re uva,{.HeIiHPlnfan,lndo14pWYldedvr(tljlt{g. SYIII:�i'_A, dYlden'if`.ebd(Idbnlfell{)FoRrletnl}<ai",dHrad}ie�n��loaC`Pbih 'v11hiT
<br /> ?i�,�04f;ilai'�.I(,iJbgV•il)IJttad)v'tJdit)u%uctr•Y,clgl{j�tl R::C,21Racrcl:'N'lll:'conteai.Lho-fly`!ri•)oJ tel Yojhe.g8'tazreRlri:4jeplivda pump 1-ProYld .R2
<br /> hl.1 rep tit r8ds p 5.,
<br /> aulerlc�drss
<br /> �Cd Eca — t
<br /> •� ��'��" .•..jy; �•w,a °tF,�,S.#,�'d''idy�'��iy�+r �r* Busi�@ss`�3YT1�1r' ,��'iv,7�4a 9���a� �li?w+. r•,. .� ,�;:.
<br /> -`s��t _ •,t:. _r. _ � i rC•" ?;I;� :-�.'i.�'`n'�� - r� ;���C�t�� t a'r i �.•r'���o..d00
<br /> 4i4.V•+',t, .4Y�".fi.�::A�,.
<br /> ` f.` ' s Ca>#ler s`ti'+•y Yr�r..
<br /> sn T
<br /> :uride� 'aiasVipflHa' letib gall anlalwt:ih Ir11 'ill'" t,'Id• •YidVbl lme,n.,,l:r,: tin eddi�lon I hW9e,lhaL le1s10 1.n f `slp7omiR,'nlfitpygor01i7nsuspanela�;ieVnvaliog;eraanlal'ol'rpnaWd pf
<br /> �h[ ,i, PoiygceF. •Y v a�?ry. .. ..._.. ..,,• v p , py am 4�
<br /> +r:�c,psW te`.+Tir kyUjMfTd¢t-iviue tCa•Pt161Pa'fleaou �ti}:, tld-"Uort�28f d ay rtSsult ltfb�J(t�p n7+111 Itp;ioS1 WUper�tlay parVlole 5 adminlstr panelllatNlblallonp tlip.0 descrlbW In Pu60o Resource
<br /> "r',.:- :Drlver's=Nme�(prlrif'_; rlvei'S S[gnature Date
<br /> �p<<•` - �. 'tom;;n��r� Offiffiffl-
<br /> Uri
<br /> LR. _ !U
<br /> .2.6 6 8 - (; V_ : �; }u
<br /> Y
<br /> r
<br /> i
<br /> t.
<br /> •
<br /> . 6.�.i _ - .ir:i5_{k'.fn..':r.h:'Srr.:Y,�•r,Jor.,'.. J.is 't:3-=w�
<br /> . ,.R. :f:,�G•.•J�t,�s.,...c,1yd•• ,(it s`�1.,,,:'::.nyvuy:.'n'4 �1'�,�� ®.•�
<br /> � S
<br /> y,-r - .s•�. �w`; 'ihl'n't$,.i�e;Gq�l t:°�f: t•1t11.e��f�:.i:�'YL§�(,'_•` ... ..
<br /> - - til, •4,y..;r,;..:ro.. >- v+•u-r '
<br /> Tt.,, .e,,ft..-
<br /> _ Kr.• ��•t�rc;,a.:�. Fsc'!ii Business
<br /> t I'
<br /> T. # �� , , ::YR...m��io�i �t _� Lq� ��:�i;�;�:P~.>::.,f .�N //� �ay�• •Ccimpean
<br /> :aa7c .,,...••f�,;.::.+�a.?1....w?.., �..,,x•,'�i. ',7'>, Yt.�,:5,;. G` �1:.'D
<br /> 4,_. , .a... . _. .'..a?% '• . .... L`It Ste e )
<br /> N, _x......,.4_ .�,.. y,,. a
<br /> . �4 Ik>.;::. .. .. :�L irriS.(venue
<br /> stsmP �i`cm�i'MeffEo; CR 958
<br /> 38
<br /> z , ess:8a e.
<br /> eY tg,s-' Adtr. 1as Ffauler?1 rnrrrar5
<br /> _
<br /> -Hauler Te►e hone'Number va
<br /> 1�;f,5;•r;�j4�!.1"}.Y.^?�.�j+�'.T`„L`'`^'"`.��1'�'t���'' A• �.;`'�.IC,ERTIFYTNAT•UNDERPENALTY OFPERJURYOFTNE 66LL
<br /> LAWS OF THE'STATE;OF.CALIFORNIA THAT THE
<br /> 1 P,• v ,. / ,_ .: ,,t 'INFORMATM?l PROVIDED ABOVE ISSRUEAND CORRECT
<br /> •.*�`<$• 1 1 �'r`yaF�'/ IY V,f[.�}�7?'a - 1'n.f n7W•ja - ,� �' -
<br /> .f I i1: <;�I PTO,CIIIly�T �epi'�Oge Numti.`r.:: ;•.', -
<br /> Halaler Tlre>Prograrr A -/ Site btlttl ;
<br /> I
<br /> PracJiit�! 5,
<br /> >.a, o+" • �•` u 1 �a a Na s/` dcir'
<br /> Hauler Karla I elsi
<br /> Kau"I i`Teiephope•Number .r - ,..!` ■ ` dies„sS:alrt. }asHauler •.. r�rriar5
<br /> • ^s J:CWRTVY THAJ UftDEg P�ALTI° URYOFTHE
<br /> t t.A
<br /> E
<br /> sOF THE�TA'fE OP ALIFORt 7NATIH .
<br /> ,3 NFDR 6A *I PROVIDED Q90VE 17 TRUE ANO CORRECT.
<br /> 1 1 - _ • 1 • • ..• • • - 1
<br /> 575668
<br /> Facilityfie►e'phone:Number.''.
<br /> d Hauler Tire Progr4fn Si#e Suffix tf ;iz
<br /> rtL.✓i (, tt,r•. T . ..e ,a:a ;•iL:
<br /> r t
<br /> �ac[Ilty Brea
<br /> �- 1� ,� TI iQ I i'3, Name/ SlY6 '_'•;.',.
<br /> • .•:,- •�.'-x,:• ,:- ; - _ City,;Sf&4e`HY1E1=��17i5.i:r:4'•',� _.
<br /> Hauler ame
<br /> "r ;i;•%7tT1�••�.•4P:l.. b�i Qi�tt5
<br /> r '; .'i'" 'gddYe$s S ►rie as Hauler::,- :intriars
<br /> Hauler Tele hon Number "
<br /> is j--• �`���///
<br /> LAWS OF THE STATE_ ICER71FY.iHAT I1NDERFFIJALTY'QPpERJURY.OFTHE.:� •�'•',:'
<br /> 2- � 4 Of CAL,FOIit�IATNAT.THE
<br /> .J '
<br /> !!!✓✓✓��� �� •, _ ;.
<br /> INFORMATION PFfOVIDE§ABOVE IS TRUE AND CORRECT.
<br />
|