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California Integrated Wasle Mar4gement Board <br /> GA Retreader Tri Log PO Box 4025. Sacramento,CA 85312.7259 <br /> E X A M P L E 1 2 3 Retread Log Number <br /> +,..Q �( <br /> waa-�e of laof("wow"INSTRUCTIONS ON BACK DO NOT TAPE STAPLE OR DUP ICATE! ! 3 10 5 5 4 4 1 1 <br /> Rc? a8 i6r,$ilSot�ei i�� J i 1 .i A� <br /> Address <br /> �.� <br /> J d G•1 I <br /> Decal Number License Plate Number DOT _ Load Date(MMIDDIYY) <br /> --*— 11 --"� --� r T' ------r-- — i_— _ r C T_ �� <br /> PPi I` t Ct� ` 1 6it �.�{i �I �� IJ j Program ID-Site Suffix Business Name./Addr$ss Pickup Count , Delixer�i Count <br /> J .. �. L <br /> ''Invoice -Number i i 1 �l"1 !� f-+{�% '1 1 ` <br /> 96 D_e4 j Ili <br /> Tire Program"ID-Site•Suutf xi Business Name/Address Pickup Count Del"" Count <br /> . .. `�: �...f...!i x I j <br /> LL <br /> -� <br /> Invoice Number . . �� j _1. <br /> ire Program I -Site SuffixBusiness,Narne/Address _ Pickup Count ,r ;'Del:very Count <br /> Mi voice NuRiber. <br /> . Lj <br /> -T-�mak- .; �,,1• ys�� �1 <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Defwu+Count <br /> �— 7- R,; <br /> Invoice Number <br /> Tire r !�� r � .. ✓ ` , `l '±�� a_ 7• <br /> P'ogram ID Site Suffi Business Name%Address Pickup Count Det<1reyCouftt < <br /> Invoice.Nutnl ei: �^ t t�1U P� ice. tA <br /> i <br /> J_ <br /> Tire Program ID Site Suf Lx Business Name!Address ;Pickup CoutN�'� Deli eiyCount <br /> __ .....• 1 tt!s,. <br /> Invoice Number I % .;4 ' <br /> C.La.. 4(5 <br /> I certify under pponahy of perjury under the Laws of the Stata o1 Caloornia that tho in4ormation Drovided above is true <br /> and correct. In addition,I am aware that falsification of this informato may result in suspension.revocation.or den al <br /> d renewal of the Waste rine Hauler Registration pursuant to Public Resources Cate seo0on 42980 ane]may result in <br /> civil penalties up to 623,000 per dtry pervidation or bdministrative penalties:up to 55:000 per v oration p&day as — <br /> de5cr�ed•in Pub4c Resources Code Section 42962. gg <br /> t j4 <br /> Driver's Name (print) ; Driver's Signature c 1 Date <br /> ' 23259 <br /> Toil Free 1-866-896-06001 www.ciwmb.ce.gov/Tires/ <br /> White:CIW M8 Copy Yellow:Rorcader Copy <br /> b0'd G2:VT 90OZ T 4ad TS02-Z7Z-60Z:xPJ •00 aili Gem uoSIIM <br />