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0. L)ul t-gibtr-1 r,�j uawtr oz k-omprienensive 't-rip Log substitution t-orin <br /> vV <br /> ro(viad UM-fzu 11-ed <br /> Name and Address of Facility: �+� � / I 1 1 <br /> 9CIC19 5. AU P—�d TPID# / 0 7 � � �t'�6�j <br /> QusniitS & Pick, up.-Deljvez-v 1-1,-)registered Tire <br /> 7�1)e of Tires Status Hauler or Exemption <br /> Status (i fapplicible i <br /> Ties Cheek One: ❑ Ur.rcgts,crcd T:r,.I-,aL.-cf <br /> Aa! or <br /> Qc of Load F-N e r <br /> -itition fit applicable'r <br /> . <br /> 0Pick up ��EA Exempt <br /> 'Whole <br /> El Goverrimml <br /> :ip codr) D Cubic Yards. <br /> Z PoundsCommercial C <br /> 17, &—ons >�Delivery CD Agricultural <br /> i�T a i u 7'- <br /> Quant-I r.:" re <br /> l* — Check One: Unregistered Tire hauler <br /> CT -ircs: 15- 47- or, <br /> -,Yrc o r L-jad- E.Nernotion fifapmkcable�: <br /> El Pick up -`I;C:MA Exempt <br /> whole 0 <br /> ;Cil)j Cubic Yards E Commercial Carrier <br /> I �EPounds ds �eljvcry CAgriculuyal <br /> Me 1,Nring Par�, Decal nu 6cl TonsSignature: <br /> if limb: <br /> Qua n-tiry or n Check One: Unreg---tered Ti--hauler <br /> Tre <br /> ' 'i or <br /> G4 puoa;ifaov.+ as ole,: <br /> E�pe of woad <br /> _ <br /> Exern <br /> ❑Pick up �:�A Exempt <br /> L Vw-hole . 0 Goverrommt <br /> �p C.dcy Ej Cubic Yards D Commercial C2 <br /> El FRoulid-I elivery ❑ <br /> CD Ag;-*cultu.-al <br /> Tzare c'( Reporting p7j-, Sip,Itule: P Ions <br /> Quantheck One: ❑ Unregistered Tire haute= <br /> Tires <br /> 0 plaieyT-75 5 or <br /> 1 Exemption ffajqpli able!: <br /> TvDe o: Load. <br /> 0 C3 Pick up -IEJ:TEA Exempt <br /> fflve) <br /> 0 (qs,7v El Govemmnt <br /> 0(52QS -- 0 Cubic Yards <br /> Carrier <br /> 1.0 El P"bunds livery C3 Commercial <br /> : Agricultural <br /> O Narne of Reporting party Decal number ❑ Tons <br /> signature: <br /> U Please submit this form to: CIWNJIK Waste Tire Hzuler Frogram, P.O. Box 4025y MS-22, Sacramento, CA 958121 <br /> 0 <br />