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NOV/17/2015/TUE 09: 52 AM JSG T~IIC[-ing FAX No, 209-3 —0879 P. 007 <br /> Comprehensive • • • Number • • InformationProgram <br /> .;,+ INyN'.�{�. r l'l'..'l•: 1a,lk �iyr' N <br /> 5200552 <br /> A <br /> aID Site Sufflx; /> D t ` r i qt facilityTelephone Naumber, <br /> Hauler Tire Program 1 <br /> R 16 :�-do2a © ® o <br /> )u1 Who�ee fire C6NtfC� Wei�Nt.ln•�t�s <br /> � Liv !moo J e� i Y"" . <br /> ,_ V lum 'Gu�bi a..We�9ht nTos� iw i tFti�1dc r � L <br /> E <br /> Hauler Name tl I <br /> U � Cl <br /> 'E50E <br /> ■ Address Same 2s Hauler r9 <br /> Hauler Telephone Nunnber M1.. ! (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OP Tk6 <br /> © ,/ ` ♦i ` Whcla Time) LAW'.OF THE STATE OF CALIFORNIA THAT THE I O <br /> J INFORMATION PROVIDED ABOVE IS TFUF AND CORRECT. r <br /> 5200547 __ B �)�] Pick Up � Delivery [A d , JG 9 11-- <br /> + Facility Telephone:Number <br /> Hauler Tire Program Ib / Site SuffixIn <br /> W, w P7e 1.lte chis ! 1Neigtit ir�Lbs e. I_ <br /> I � 6I : '•" ;;r Volume Cgblcs '�;;JIve�11t i2,Tvn9 :;^ yw �, <br /> . . <br /> E Hauler Name <br /> Hauler Telephone Number Addre s a e as h t f„n;,r, <br /> °'e411 'f la r d Y ti Y ti <br /> y/ .1p 1 r (N/A�6r l; I CERTIFY THAT UNDER PENALTY OF PERJURY 0,.�..E <br /> ��—L C](�q� �f I�$2`y,! � �. ��Afholc Tlfa i � LAWS OP THE STATE OF CAurORNIA THAT THE <br /> — 4 INFORMATION PROVIOEO ABOVE IB TRUE N/ D CORRECT. <br /> • • - • • ■ b' • f • • • • <br /> 5200535 E <br /> Pick Up €e-r"ry \ E a <br /> °' Facility Telephone;Number; <br /> Hauler Tire Program ID Y C <br /> Site.Suffix ,a�t�r <br /> ,�( <br /> Wh {a`tttCGt' e�l �,bf;ra <br /> L � 1 1� �,;.I d. • �ft+L!VQIy�Jme��ubf����I�.J:'wv��4�tl�k 1A.��� �,r� �I f cJt?�,i��:i u :+t,\, _+d'�,f'I <br /> I <br /> pHauler Mame ; � . . P ze <br /> HaLlisr Telephone Number Addresslame as Hauler <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURT OFYHE <br /> �] UD WBola Tfra�) u+ OF THE STATE OF CALIFORNIA,THAT THE ��V <br /> / U • ` INFORMATION PROVIDED A66VE IS TRUE AND CORRECT, <br /> Received Time Nov, 17, 2015 10: 08AM No, 1421 <br />