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Catirornla tntsgratod Waste Management Board <br /> CA Retreader Trip Log PO Sox 4.725, Sacramcnto,CA M12-125D <br /> .. <br /> j2X A Mi P L,e1 1 213 Retread Log Number <br /> wM&-ao wowoaroti)INSTRUCTIONS ON BACK DO NOT TAPE, STAPLE OR DUPLICATE R 6 10 55 41 1 <br /> Tire Program ID Site Sufflz <br /> Phone Number(tncluds area code) <br /> Decal Number License Plate Number DOT Load Date crtim/0 ,rYY) <br /> SDS q q E- <br /> w_.. <br /> � R � P <br /> ire Rr` rarrf`;!D Sete SufftX� -' .Business;Name I Address Pickup Count Delivery Count s <br /> Ott - ,o� 11 � y I <br /> .Tire Prog m ID-Sit®SLfflx !Business Name!Address ! Pickup County Delivery Count <br /> t <br /> I Invoice Number 1 1'�Q <br /> jj <br /> thea Prograrnµ Sfte Business Name'lA�ldte�'s Pickup Count ! Delivery Count ' <br /> .IMP .W+ MYe ..`... X': •�:_ilw5(s" t�x'.iw.. .�. .. <br /> Rr�- <br /> 3q q 3 = p <br /> :Tire Program ID-Site Suffix Business Name J Address Pickup Count q Delivery Count <br /> I t <br /> i <br /> Invoice Number <br /> i <br /> :'Pica Prv�ram fD SFLe�SuffiX M'-`;; ;tz0 ,..: siness Name_%AifdFess r ;it .+X Pickup Count Delivery Count ; <br /> -r Y ai <br /> k• � 1 <br /> 7 <br /> Tire Program ID Site Suitlx ;Business Name/Address i Pickup Count Deliv®ry.Count <br /> Invoice Number <br /> I ' <br /> l i <br /> cortAy urrd9r penalty of ptvr)ury under the tsws d the Stale of 09lifom a that tl2e information prov dad ae <br /> bovie true r <br /> and correct. In addition.13m aware that falstlicalion of this a2formation may result in suspension.rovocatan,pr denial I Totals' '56of renewal of the W ase <br /> Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in J <br /> civil penalties u to$25,000 per day,per violation or administrative penalties up to$5.000 per victta i per day as <br /> described iii Pu ie Resources code aectron 42962 C ------- <br /> I <br /> -._-__ <br /> U <br /> D ver's Name (prim) Driver's Signature Date <br /> 23259 <br /> Toll Free 1-866-896-0600 / www.Ciwmb.ca.gov/Tires/ ® ■ <br /> White:ClWh18 Copy Yellow:Retreads'Copy <br /> 0'd <br /> cc:VT 900C Z qac ZSO�-c-t7c,--60 <br /> C. o� aatl fi�� uosit� <br />