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SEP-10-2004 11 :18 AM MIDAS- AUTO. SEPVICE <br /> 2093699430 <br /> Cal niaTntaintsd Wawa ^rent Board <br /> CA Ung nr rl�Mas and U"d Tire Manifest Z8, Ma.:sebram*.C-",ores 12se <br /> I <br /> Manliest Number - <br /> AMPLE1 ��3�� L M 2 _1_4 5. 2.9 8 3� <br /> 1NSTRUCTtONS ON BACK <br /> Hauler i(gptrunal-Ad(rr *#1GE TIRES <br /> rdarrlr1 900 S.Cherokee Lune <br /> ,�.:',r_t�,^-'•=s Lodir 3398 <br /> 240 <br /> (209). �I <br /> Haulerts Business Phone j <br /> {include area code? 1 <br /> Hauler Exomption of apokabte) <br /> IT / �_.� / �_._�� �L�' I-——� t • � _ ! r ._� �]Government�LEi4�x8mpt <br /> Load Date(nu►uu�onY) Log Number __ _ ❑Agriculture O.�n'O"Ca6*rl <br /> `• � �_t'�_l_.� �l._� _ � _ _� - ' � I � 1 "� maul <br /> {I1diC8tA(if apptloabte)Q to Trarfsa--- <br /> License Plate Number _ St_ata _ gecal Number _�_���_...____.._.__-.. - •- <br /> _ - <br /> pCanfidentiatity Claim:The Information provided in Pan I and Part It of this,form should he COrlsltiert3d confidential,proprietary,and/or trade secret. <br /> accordance with Title 14•CCA.Section.17041 et,&eq,should any member of the public request discloStlr9 of this Information,r request mat C)WMB contact <br /> me at the address and lefephone nttmber-abQvs: <br /> I certify that Under penalty of Ppryury under•trre laws orl4he Statf:•of t.alifornin th,,t the.information provided above is Rue and com!ct. In nddition•t am aware that falsification of this <br /> ' informallon may reSuit in suspension,revocation,or rlenio of ran0wal of the Wsety rirn:Ha!irer 11e9l.=traliorowsuant to Public Aesout"Code r#xion 42M and may resOt in civil <br /> j ponaltles Up 10$25.01x1 per Oft per violaliorl or administratNO ponall!e5 up to$5,000 Per vrolwiort per da ne dezcrft din PUUI;e RCW%1 r:en Ccem SeOtW QW2. <br /> = �" , ,�.,_ ; rel (, , :.�• .. • <br /> Driver's Name(print) N Driver's Si naWrd-- Date <br /> ®usrnes7i Nifttie Facility's Business Phone()nclude area code) <br /> _{T - L...... <br /> •Number dt Str'qiet Address <br /> t ; AddreOB Atldrm+s <br /> Q Sar"As <br /> -•.., Change Of <br /> i t <br /> _State _..p Coft <br /> _ ___-----•-_-_. <br /> 171 <br /> Tire Types and Amounts Intended Us <br /> ❑Passenger ❑Oversize �Retroad/Re <br /> — i-,.�. <br /> ELI Tire Program iD Site Suffix 11 <br /> • ❑Hecycle <br /> ❑Truck ❑Fuel <br /> -E 11 <br /> .L._._1... 1•�.. r,,. `<::, '•' l ❑01t3posaUL <br /> Comment Area tai • - -_ -.-.___-_ <br /> OConfldentiality Claim:The information provided in Part I and Part 11 o1 this f 8hQWk"4APnsiderAr+.,,nG fnntial nrruxlat ,. <br /> In,8000rdance with Title 14,CCR,Section 17041 et-seq•should any member of the public request dlvctoautt:of thi%intonnatlon,1 ��Vm'W 6 <br /> rpgyeatyraa ►+► <br /> contact me at the address and telephone number auove. +, <br /> I certify that urxfer penalty IN Penury under the lawn of the Slate W Callfomia that the information pntvlded is truq and cotrect.In a"don•I am awarelh6R�altlG pVl <br /> ! inlormatlon may result In civil Penalties up to$25,000 per day.per violation or administrative penalties up to$6.000 per violation Per day all 06scrrbed In publk, OR <br /> j Representative Name(print) Representative+aslgnetufie-,.•. Date ° <br /> TON'Free 1-866-896-06001 Win ► CiWmb:MO,W s/ <br /> iwhite:CIWMB Copy pink:Time Dedlcr/Oencrator/En(f(J �gGf Gly Ye1e, <br /> +I .... _. .. spy . <br /> I_ ,,:-• VORM NO.vngr/AtLnwMa ntt:.ryr y�, •�- <br /> LLL <br /> i <br />