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Toll Free 1-866-896-Q6001 www.ciwmb.ca.gov/Tires/ <br /> e, California Integrated Waste Menepemenl Board <br /> _ CA Com reht:nsive Tri Log and Receipts i0002 P.O.Box 1259,sawarnento,CA95012-1254 <br /> AMF ,� 1z3 <br /> Comprehensive Tri Number <br /> u <br /> Ans""rwftt(f0A)1NSTRUCTIONS ON BACK OF PART 2 UO NOT TAM STAPLE OR DUPLICATE <br /> dy ahmina Ih1a CACempr 4eMBr.Trip I,sg and RvAbt,the s*e4s)request IMI Inc In(Ormauea pr Wded os Lhla form WU W eonsldered aonndendal,propdawty sn wd Iteda ae&aL In aeeetdwda YAdt Tide,11 CCR,S.edaA <br /> 17ea1 aL a,t},if s.quest k made forcxn owure of Ufts Infoanaedn,the CfWMa uq.oon"Usl thea{pnar(a)of ddaterm al Lhe address W ufejhe..q.fi6v pro•INd Uh form or fM1VL <br /> Hauler Address <br /> Business Name <br /> Address p /3GJc yD <br /> City,State and Zip <br /> L� j G Common <br /> Garner L— <br /> I cwM under povey of F•Qury WMM?IM lows of de$ate of Caikmfa UW Qts rnWovados pwYkIed Nwe Is he and CaMOL In a6dw,t sal•wma 01A f w"Van of die Woreuuian re•y laa•.a fe W*waan,rowdo6on,"d•o41 or fore-sl of <br /> Waala Tire Hauler Repktaden OUMMA n hbk Ruourma Cods sealoO41.960 and my tsuft 1A CM pwaldaa up to f 25ACO pot day,pat.sdaifde et b -p 0 Idse w lo MON per violation par day a duc&od i1p"a Reswrcea <br /> Cede aerator�xtn2 r <br /> Driver's Name(Print) "OV; ature 6ate <br /> 3248875 -- <br /> Hauler Tire Program ID / SiteSuffix Facility Telephone Number <br /> ° r <br /> PGU-PEDEUa <br /> I";y�ill�u3lnfax <br /> 1101012-1316131 — 0 ifs <br /> Hauler Name c.il�y,�ri r, irr 7�,• �c(�,�c i (1)„R_ <br /> Mauler Telephone Number !” Address Same as Hauler <br /> '� J I CERTIFY YHAY UAOER dfHALTY Of PERJURY OF YNE <br /> U Q tC•lJ /q �9• LAW$Of YNE STATE OF CAt.I>'ORIM TNAY YHe e. <br /> / /J 0 <br /> 0 1110 ME e- to tr <br /> 3248875 BEWER 1 —w0 <br /> Hauler Tire Program ID 1 Site Suffix f=acility Telephone Number <br /> r G I <br /> 000-aa000 �� o <br /> tAlfe � <br /> Z. 3 — U N� r o A "res v,N+> �c%S <br /> Hauler Name CItZ(1�P&.1anG§4lp4,j4km4y 7 <br /> 'Al. /-.I � s*dn1(Po�te�e`MK . �. , f7s 3 3 4 <br /> Hauler Telephone Number N n Address Same as Hauler <br /> I CERTIFY THAT LINGER MALTY OF PERJURY OF THE <br /> C1 y w s")6 r UW Of THE STATE OF CwFOR"THAT THE <br /> pIFO O ABOVE 12 TAN <br /> 1 a s 1 • tIRTMEMIUR1 <br /> 3248875 -- A <br /> Hauler Tire Program 10 / SiteSuffix Facil ty Telephone umber <br /> 0 <br /> / 0 .� 0 ��aaa <br /> r��• +Ilii1131 ;};��; <br /> ?_ 6 �• <br /> Hauler Name 4s'�'31 d+ 7nld f�pl9l� <br />