Laserfiche WebLink
State of California Department of Resources Recycling and Recovery <br /> CalRecycle 204 (Rev. 04/10) (CalRecycle) <br /> Unregistered Hauler & Comprehensive Trip Log Substitution Form <br /> l� i►1��;�- ���w�Grt.c.,c ct.� T;� r <br /> Name and Address of Facility: �l J` Y N TPID4 l l ( 1 � -M <br /> Col- Ci 2, s'" <br /> Date& Name License Plate& Hauler's Name/Address/Signature Quantity& Pick up/Delivery Unregistered Tire <br /> Decal Number Type of Tires Status Hauler or Exemption <br /> (if a licable) Status (if applicable) <br /> Quantity of Check One: ❑ Unregistered Tire hauler <br /> "r v W Tl Tires: O� <br /> 2 / (License Plate) (H tae) �, 1 or <br /> 11 `-' Exemption(if applicable): <br /> —r ( dress) Type of Load: ❑Pick llP p <br /> tate) <br /> Lam—Whole ❑ LEA risme t <br /> ❑ Cubic Yards ❑ Government <br /> Commercial Carrier <br /> iCi�y) (starc) (Zip Code) ❑ Pounds OWelivery ❑ Agricultural <br /> Name of Reporting Party Dey'I nI n`omb`e�r — Signature: <br /> El Tons Or <br /> (ir applicable) <br /> ❑ No ManifesUCTI,form <br /> Quantity of Check One: ❑ Unregistered Tire hauler <br /> (License Plate) (Hauler Name) Tires: Or <br /> Type of Load: <br /> Exemption fifaoplicablel: <br /> (Start) E] Whole <br /> (Address) [IPick up ❑ LEA Exempt <br /> (Cay) (state) (zip code) ❑ Cubic Yards ❑ Govemment <br /> ❑ PoundsE] Commercial Carrier <br /> ❑ Tons ❑Delivery ❑ Agricultural <br /> Name of Reporting Party Decal number Signature: Or <br /> (ir applicable) <br /> ❑ No ManifesUCTL form <br /> Quantity of Check One: ❑ Unregistered Tire hauler <br /> (License Plate) (Hauler Name) Tires: <br /> or <br /> Tvpe of Load: Exemption(if applicable): <br /> (Address) ❑Pick u <br /> (State) [3 Whole p LI LEA Exempt <br /> (city) (state) (zip code) El Cubic Yards El Government <br /> ❑ Pounds ❑Delivery ❑ Commercial Carrier <br /> Name of Reporting Party Decal number Signature: ❑ Tons ❑ Agricullttu ral <br /> (!applicable) <br /> ❑ No Ma»ifesUCTL form <br /> Quantity of Check One: ❑ Unregistered Tire hauler <br /> (License Plate) (HTires:aulclName) Or <br /> Type of Load: Exemption(if applicable): <br /> (Address) ❑Pick u <br /> (State) [I Whole p El LEA Exempt <br /> (City) (state). (zip Code) <br /> El Cubic Yards ED Government <br /> ❑ Pounds ❑Delivery ❑ Commercial Carrier <br /> Name of Reporting Party Decal number El Tons ❑ Agricultural <br /> Signature: Or <br /> (if applicable) ❑ No Manifest/CTL fort <br /> Please submithis form within 30 days to: CalRecycle, Waste Tire Hauler Program, P.O. Box 4025, Sacramento, CA 95812 <br />