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Unregistered Haulbafr & Comprehensive "drip Log Substitution Form y <br /> Forvvald, WAXAJIhy <br /> Name and Address of Facility. gC961^9 5. Aa��, d TPID# F /T/ JL91 -7 0 ` 4 I- L�T <br /> k w. - 04 175- <br /> .3 F'1 -T ;cense Plate IatuleT'r�iat-e'Adde;a.1�inakus; Qu3ntity& Pick up.,Delive^V Unregistered Tire <br /> )ecal '•1-umber j Type of Tires Status Hauler or Exemption <br /> - - <br /> ifapplicab'le <br /> St3it15(ifapplicablei _ <br /> r TiUrrcgistcrcd Tsc t]a L:cr <br /> Ga/� J <br /> Quoin L' ;,(f_� Chc-:k Onc: <br /> V res l (�f <br /> n Fla;e; faauE f OT <br /> i :} ,, , ,xenv(ion fit applic2 <br /> li t, _ — Tygeo:Load O Pick u EA Exempi <br /> 5 zLe <br /> 3 C I s� -ip C.o ❑ Cubic Yards. ❑ C,oirerrtrnc l <br /> ❑ Commercial Catner <br /> ❑ Pounds <br /> -DkDelivery c,� Agricultural <br /> Namn�A,eoortin= P;-„ i?ecal number 'l. � ons <br /> sig:ature: <br /> j If;�lieable: <br /> Quara:�= Check One: Unregistered Tire hauler <br /> or <br /> 'I icense Pate) (Hw <br /> _ i �semotton fifapm'cable): <br /> �(/ i i �. _ _ vy' Load <br /> ❑ Pick up E•4 Exempl <br /> (State) i 't �'�f< � ���x ❑ Cubic <br /> � f `T * ❑ Governmert <br /> ;Cn>' (5w ❑ Cubic 1 girds <br /> -) ❑ Commercial Came: <br /> ❑ Pounds felivery j ❑ Agriculturai <br /> Name OC Reporting Parry Deifcal nIicuyrinVbcr —Si-g-rmlre: � � <br /> �Tons <br /> ! <br /> OuarrtprQf Check One: G Unreizistered Tire hwlc <br /> _IQ ! I Tires: --� or(License Plate i n+ �• t <br /> 10;. i, � E.xempuo.;iiia?n;;caS el: <br /> j � _ s l spe of woad: ❑Pick up €A Exemp! <br /> {Statcl _ A_ f�� ❑ '"'h°lP ❑ Governmmt j <br /> (Cry e, : rcpCodc) Cf Cubic 1'ards ❑ Gommcrcial Cam( <br /> L!/ ❑ l ,nds Delis e} <br /> ❑ .4d cultural <br /> CL Name of Repc.rling Pam, Dccal number7ons <br /> N Sign [tures <br /> ri76fi' liable; <br /> q/ Quant iq f Check One: ❑ L-nregistered Tire haule_ <br /> {© Tires <br /> Or <br /> O //� (Licer a Plate) (Hao j (i <br /> tD l/�� S ( Ttw o:Load. ❑Pick U i Ekr-E of fem t abler <br /> p ! (c'�te) C ❑ Ufhole P A Exempt <br /> Cubic Yards l ❑ Government <br /> � M <br /> aw lam ,� pC�� ❑ Pbunds elivery t ❑ Commercial ial Carrier <br /> O of Reporting Pa Tons E] Agricultural <br /> Pc 8 rh Decal number Signature: <br /> i[ Ixabic <br /> oPlease submit this form to.- CIW;IIK Waste Tire auler Program, P.O. Box 402 MS-22, Sacramento, CA 95812 <br />