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11/30/2005 14:24 FAX 2099573972 FedExKinko's IA 004/005 <br /> aFP y <br /> CA Uniform WW and Used Tire Manifes <br /> PO MIX <br /> :�L !C 71 �2 3 ' ==11, 11 oil <br /> JA MiP: Manifest Number <br /> INSTRUCTIONS ON BACK DO NOT TAPE, STAPLE OR DUPLICATE M 5 - 22052* 051 <br /> 07 It, —,WL-ru•r'wall TiVe 14 00 n !AW I l GRIMID <br /> PART 1:, TO BE COMPLETED BY TIRE HAULER <br /> PLEASE PRINT FIRMLY <br /> -7 <br /> Hauler <br /> ICk p. Delivery <br /> Blisinoss Narna <br /> .-,P,I.ea,s.6'cdm0'jet6Jf OLItsideCalifornij: /{('IC res <br /> . Zip <br /> -DImp6ti/Export <br /> City. SlateL <br /> Witty onn. e, <br /> Load Date wis <br /> M!DD!YY) Log Number Hauler Exemption(rf appjivau,;)* <br /> L <br /> U GOVOMIT10111 M LCA Lxoniri <br /> 12- <br /> L Aril'i(AIRIAM.- 0 Cornfiion c:vrir.-a <br /> License Plate Number State Decal Number Back Haul <br /> Indicate W <br /> (it Vitt; <br /> information may r4ttiuji revs-c-Itim.or kit 1ho WaIto Tio, rUt7lir 4 <br /> 41i0'41jltd� <br /> 1(,$_15,000 I ancl nvw roi;oi it,ow <br /> ............. <br /> ................... <br /> river's Name Ipri'll) Driver's Signature <br /> Date <br /> .PARTII: T013E:d6MPLF-:TEDBYREPRESENTATivr-.,OF.TiRr--DEALER Ofd WASTE TIRE GENERATOR OR END-USE FACILITY. <br /> USE ACTUAL LOCATION WHERE THE TIRES ARE PICKED-U- P OR DROPPED.,OFF... <br /> PLEASE PRINT FIRMLY <br /> �Susiness Name Facility's Business Phone <br /> Number& Street Address <br /> City State Zip Code ❑ <br /> Tire Program ID Site Suffix Load Load Amount . <br /> Wholo Tire <br /> Count <br /> t4-Pounds <br /> LYolUnle <br /> In. .0 W3 <br /> wholo Nk-li <br /> ...... "Wr Whole Tire colint <br /> ............. ....... <br /> P-nx-spripor Amaint (Dvorzii/t,Arnouni ur.(3 ...... <br /> 1A Relff-10"rinLISO 171 W?cvCfo 1-1 r:upi <br /> COWITTIOV0 Aron <br /> fiLlCk AM0110 <br /> CL <br /> 0 <br /> I cerGty 11-1.,jitit'Xiot v;:nally of Va'.q:AIV off"Jor 01c,faivs M State ot raiilkirllk:)III;III,lk; -Wovided abok,-:v; III wo L;Crrxt.I,)nirl(iiiion.I :I.;it <br /> it)I[mriaw"'3 tyl;',y r"mil In civil nwirillex.'kilt,it, I),!, rxr vinlaiwirt('V kip I`I-:r vl;kation rof ekly;I!.; <br /> .......... <br /> ............ ............. .............. <br /> Representative Name i(orini.) Representative's Signature Date ?6 187 <br /> Toll Free 1-866-896-0600 / WWW-CiWMb.Ca.9Ov/Tires/ <br /> IPW10101011"WA-19 <br />