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California Integratea waste Management Board <br /> CA Retreader Tri Log PO Box 4025, Sacramento.CA 95812-1259 <br /> Retread Lo Number ■ <br /> E xA MP , L;Ej 1 ,2 3 s <br /> rw Ot <br /> m oe(mwosroa)INSTRUCTIONS ON BACK DO NOT TAPE, STAPLE OR DUPLICATE R 1 1 0 5 5 4 4 5 <br /> Tire Program ID Site Suffix <br /> i <br /> t <br /> g 3 g � <br /> I 9 <br /> Phone Number(include area code) Lo / <br /> i <br /> Decal Number - License Plate Number p DOT, I Load Date(MM/oolYY <br /> ire.P�o�'eaiD=�S e�iftx ': r �f�s� � � � d�s-•rl/ �v'•> � � �z �ku Courit Delivery ount <br /> 3 ! 7 <br /> _ ... --. . . . f e^L ..,.,..s� P � rY <br /> '��;�,, ��•' SSS 1 �� � � t <br /> Tire �ID--Site Sufflx�..�.}:.._....._ <br /> Business Name I Address f Pickup 66urt.71 <br /> _ C40try Count <br /> j 3 3 b �8 - d � �,vt���clJ�s�w✓►C�� <br /> i�r�..� <br /> Invoice Number V � D, l <br /> !Tire Pr nil Sde Su#fiX.;: . -.Suslne —Nam__e/99Adfdr�ess_ r _r ; ,Y Pickup Count Delivery Count <br /> 3 <br /> 1 © s8 'W <br /> Tire PrograID Site Suffix gUSinOSS Name!Address Pickup Count Delivery Count <br /> Invoice Number 99 P, C L "q 9 l b -4 �I <br /> �.Ll goa� 'a+rtlo3/'�1�0-1 �..pr� G��• �� � ( j <br /> �irret Pro .�� <br /> racif 1D Srte Suffrx Business Name/Add � ,: w";:' Pickup Count Delivery Count <br /> Tire Program ID-Site Suffix Business Name/Address Prckup Count Delivery Count <br /> Invoice Number <br /> a <br /> 63L4 <br /> itonify, r penalty of perjury under the yaws of the State of California that the informalion provided above is true <br /> and correct. In addition,I am aware that fats fieation of this information may result in suspension,revocation,or denial'Totals: <br /> of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code samion 42980 and may result in V <br /> civil penalties up to$25,000 per day,per violation or admiristrativc perd)V b up to$5,000 per violation per day as > > — <br /> described in Pubic Resources Code section e2962. _. <br /> Driver's Name (print) river's Signature Date <br /> 23259 <br /> Toll Free 1-866-896-0600 / www.CiwMb.ca.gov/Tires/ <br /> . Whft ClWM8 Copy Yeliow:Relreader Copy ® ■ <br /> �'0 'd V<*:VT 9007 T qac p� •00 earl Gem u0sitm <br />