Laserfiche WebLink
11/30/2005 14:21 FAX 2099573972 FedExKinko's 160011005 <br /> wa, <br /> � <br /> CA Uniform Waste and Used Tire Manifest <br /> Ile,MIX 1: <br /> c <br /> M; VF ;lv:t7l <br /> Manifest Number <br /> 8�al;loj caldn I'll, <br /> C w INSTRUCTIONS ON BACK PO NOT TAPE, STAPLE OR DUPLICATE <br /> ih (A Undoin 'Illd t j:'4,(i fill? ffic�. NJ - 2052062 <br /> !Wi*?1! . on lljlf�itsim In"do <br /> I Ill Ljccclii�#if ic'll will.,:*ifiv I.:,.M1.�11a.twr I I Yo-'It-1 it reqat:e;i uric?tof qj!:t:i t:%,otjf%.IF. <br /> . df ]II.niincy(S)of thj�folfe,g1l JJI,,sotwlrproyieli:1Ijt <br /> PART 1: To BE COMPLETED BY TIRE HAULER <br /> PLEASE PRINT FrAMLY <br /> Hauler <br /> ck Ll' <br /> P <br /> Bwqiriess Nai7­Icl <br /> II�Odtslcjp ccilifo r I.a: Ac dr�,s <br /> Please compiptel:". n j ( 8 <br /> City, SIM(,. –7 <br /> ip L <br /> S <br /> Load Date imt,4; ryyy) <br /> r), Log Number Hauler Exemption <br /> . . <br /> 1`11:wilt [I LFA Exampi <br /> License Plate Number State Decal Number flack I foul <br /> it Indicate (it awilirahlil) <br /> In Transit uvirtgi- <br /> let t.,d j-jaujL.j <br /> thill 1-:%'lly Of Pcl"PIIV UOLICT thO-14M.-,Of 1110 SUO 0-f(:,'41ilornia rhnt iho Ifti-nrici­cwoci. in;.,igimoll, 001;'I'A'jift'.J!J�ij 11*11... <br /> el-N-11 01 lI*Wa!'*,Tro 1-4,1011jr jjjCql pkjf�6L[Mf 10 PTItIlk: Codu <br /> 1P io Vnl PO)'fA44y lMf vi(iILjIj.-)n r)l,;j,it,I it jj:.�jj f1Ve1Qfi(?*'Ill)JC) por <br /> ..................... <br /> Drive <br /> r's Name(prw) Driver's Sigrinit-61--e Date <br /> PART II: TO BE COMPLETED 13Y REPRESENTATIVE OF=TIR8DEALER ORVASTE TIRE GENERATO <br /> USE.ACTUAL LOCATION WHEAE THE TIRES ARE PICKED-UP OR DROPPED OFF. R OR END-USE <br /> PLEASE PRINT.FIAIIiIIJy <br /> Business Name <br /> Facility's Business Phone (inriticic ilrl,,l mrie). <br /> 1 . <br /> Number& Street Address <br /> City State Zip Code <br /> FA,Wm.::;0,1me As Hauler <br /> CIUML.11?Ot Acwisx;r.: <br /> Tire Program ID Site Suffix 19ad Type load A 01bunt-, <br /> .Tire COUn <br /> igi-it it, rOUnds, <br /> Vt)IurTiC ijbic ylwfs Weight in Tons Whole Mni)cmonly <br /> nr,-Irlf)tx Amount Overuikc Amount InIonded Wo. <br /> 0 <br /> .1 Fill,, Q <br /> C'rimment Ant:)Trock Atilowil <br /> 0 <br /> 0 .. <br /> .......... <br /> Inw...;of!h 0­:;:.,s1_'1,"it r.1lifc?­r'nn litol RK, kill ve i <br /> ill".at <br /> reilljoll f..(.r viewiion pjecri.j <br /> ullollivilioll nuly Jwfulli'v7i up to t'�!S,004)por smy.poe Violillior, <br /> Representative Name Itni; Representative's Signoture Date <br /> Toll Free 1-866-896-0600 / WWW.CiwMb.ca.govfrires/ <br />