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�—vw�tcj v" j1at-11vv 4x k-umprenensive trip L0g ,-5UDSUItUtI0n ivorm <br /> Name and Address of Facility: '-Forwd, # <br /> q�q'�9 5. TPTD , <br /> Qumtity& Pick upiDeliven Unregistered Tire <br /> Type of Tires Status Hauler or F:d"ipacit <br /> — 1}-J�"�n;�. I^..;��- R —�l-� IN�eff/�tt' Status (ifapplicablej <br /> QuChcock One: Ui.rcgtyocrcd T:r-. hau.cr <br /> TiTe'5L�n', L <br /> Hall or <br /> !:jernpdorn(if ar)p I icable 1. <br /> LQe of Load 0 Pick up EA Exemp! <br /> 'Whole ❑ G'ovemmen! <br /> ❑ Cubic Yards. Commural <br /> 7cuil C <br /> Pounds Veq <br /> 'ts(Deli -a I <br /> 4� -X 2'6( <br /> C3 AgTicultuT <br /> �ons <br /> Qt:antcty r. Check One unregistered Tire hauler <br /> —ire&: <br /> pive! or <br /> 7 vre or Load: Pick up 1 7'E.Ne l2tion(If2MIcable): <br /> [I whole ZEA Exempt <br /> ;cRy) Cubic Yards Govemmvv <br /> -:Fp ❑Cc-',c) E] Pounds Commercial Carrie,- <br /> IVCFY ❑ Agricultural <br /> ame 0(Roporling Pam Decal nurnbri Signature: 0 Tons <br /> Oulpfin,or Check One: Unregincred Tire hauler <br /> res: <br /> 01 <br /> 'E�pe ot'Load Exemptioa fifavm;�--ab lQj. <br /> 'Ad,t;i) <br /> El Pick tip _-�A Exempt <br /> ❑ <br /> er-y, <br /> [J— Cubic Yards C <br /> ❑ ornmErci2. <br /> v <br /> El F�)uzids DehED Ad cultural <br /> 0 F Reporting Drcal number Ions <br /> N <br /> Quantity of Check One: ❑ Unregistered Tire haule- <br /> (License Place) Tim I or <br /> ENCT110 Dn(If aml iciabj'e): <br /> LO CP (Addmss; TvDe of Load. E)Pick up iIR=E,'k Exempt <br /> 0 Vfhote ❑ GoverriMMI <br /> I (Cav" El Cubic Yards <br /> Ln El Pbunds >eelivery i C1 Commercial Carrier <br /> 0 Name of Reporting PartyEl Agricultural <br /> I �t Decal number Signature. D Tons <br /> 4-) if — I I <br /> U Please submit this form to. CIWNIIK Waste Tire Hauler Program, P.O. Box 4025, NIS-22, Sacramento, CA 95812 <br /> 0 <br />