|
SEP-10-2004 11 :17 AM MIDAS_ AUTO. SERVICE 2093699430 P_ 06
<br /> U, orw `W. Ste and Used Tire Manifest cow b ' '°" "w """"8^�}g°"'�"I s° ' -
<br /> Voaw rgQr9rnerttKO;Cil e1�t259 ;r
<br /> 1�t L f E )( -1A P Er1!12131 AAa>t lliiT�f fWsEnber
<br /> g �... :
<br /> Ioam;t INSTRUCTIONSCK A .
<br /> FART ON BA �T•. 's ::1t/'„, ::g.;. ,,.
<br /> P1 Hauler
<br /> l,Sin�=s5 IVert1Bl AU IMAGE TIRE a,WASE(,
<br /> 9W S,C14FROKEF.I-N_#1
<br /> Addt'e3:>5 WD1,CA 9524b
<br /> J Qe City. ,",slate_Zip I (2M U3-8442
<br /> Hauler's Business Phone r'—' "
<br /> (include area code) LJ El
<br /> —
<br /> / Hauler Exelriptlbn (if ti*iceble)
<br /> (� l 1 !; �, ❑(dovernml rnij b LEA 610n,
<br /> Date( nrv) Log NumberCIA
<br /> '
<br /> _ z , Cindicate(N aWioebte)
<br /> Irr tta)r,eit
<br /> �•
<br /> "'rise Plate Number State: Decal Number
<br /> r l t 5dentiallty Clalrry:The infoiiaa plpvlded i�an IanJ Parl II of tf,is form should be considered confidernJEif,prpp►1lrry,Otldor treble>aecrel.In
<br /> e with Title 14,CCR action 17041 otseq,shoany member�f 1 e public request disclosers of this'Informgfioh`1 re tieat Wm awlial twnt4�;
<br /> j address and telephone number above. "'�
<br /> ander Penalty lot under"*laws of ine.siate of Camomia that the intoraiation �¢,
<br /> pe lty per)dry prn,rldCJ ilbovele erirr.,got1 correct.in atldltfon:t �e Nnfieleiiie6non or Ih(a:
<br /> 6A),result in auspension,revocation•or daniai of ienewal of lou Waste Tire HaulerRegistr4lion p ant to Public R�sances t:.gde.l: 42960 anti mayi'eeufr in ,
<br /> n it,$25.000 per day,per violatbn or adminlalrAtwe penalties up 10$5.000 ppr',Aofalior,per d13y sodabed in Public fy�•
<br /> �''}'' j:-. s -'lobi: .:.r. •:� . .
<br /> ver's Si natuve
<br /> s Name ri Dr'�
<br /> bY.
<br /> t ACII_f
<br /> Ak1dress abol)
<br /> tless Pieimi FBCIItty' Busiflf "i�l101 lutfe ail. .i te)'
<br /> r •.}}I.'
<br /> , I.
<br /> -Ad
<br /> !ct.Sil�)l?r$t eel Ar�dre$8 y _..�,�,.� rte•. ,,., •{�
<br /> P
<br /> ,
<br /> Changapf
<br /> iibwreae
<br /> _
<br /> State Zip Codi'
<br /> Tire Types and Amounts
<br /> r ❑Passenger ❑Oversize.
<br /> "w use
<br /> i program ID Site Suffi --�= I--
<br /> Th
<br /> -L _TFI!
<br /> LOad T (]Truck' ❑Omer #40 Ftifell
<br /> :. (.-
<br /> elm dpA..
<br /> Load A
<br /> Comment Area
<br /> i'ti fb f identlality Claim!The information provided in Part I and Pan II of this forfn should be considered conilderltW,.p�rympir lit'
<br /> :i,,sce with Tills 14,CCR,Section 17041 et.seq,should any member of the public request disclosure of title infordiay�,l it cii it CI MB
<br /> i; •n,•at the address and telephone number above. lL�
<br /> .,i ender penalty of penury under the laws of the State(1 CailKuni,)That the intormsdon provided above 1a true a rw".M uwl(lon,I Etta• tt tlsificatWaOl Ndd't
<br /> ,t i bay result in civil penaitia up to$2&,0W per day,per violation or administrative penalties up to$6.0(k)per Vio n per day ae d03crlbOd •blip - .�
<br /> 1-sentative Name(print) Representative's Signatur'rs'� Q®te &
<br /> Toil Free 1-866-896-06001 vttww.C1WMb.Ca.90v/T1re&
<br /> Wnrte:CIWMB Copy Pink:Tire Facility Copy 'Yellow:Harder Copy •,
<br /> ! FORM NO.M.�rtpoidWlYiP REY 7tlae��� S .: •.
<br /> �eMYWlte/Y`t� ,!
<br />
|