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Rev 4-2003 page 1-4 Mailing Address : P.O. Box 14909 Knoxville, Tennessee 37914 Phone: 865-540-4409 Fax: 865-540-4407 www.claibornehauling.com Physical Address: 6210 Rutledge Pike Knoxville, Tennessee

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Rev 42003 page 14 is a specific form used for reporting certain information to the relevant authorities.

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