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State of California California Integrated Waste <br /> CIWMB 204(New 8/05) Management Board <br /> Unregistered Hauler & Comprehensive Trip Log Substitution Form <br /> Name and Address of Facility; LOVELACE MATERIALS RECOVERY FACILITY 2 6 7 9 5 9 0 1 <br /> FACILITY AND TRANSFER STATION <br /> 2323 E. LOVELACE RD. <br /> MANTECA, CA 95336 <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 /> h if applicable Status (if applicable) <br /> r �/y Quantity of Check One: Unregistered Tire hauler <br /> ��9 ; At 11 G k) OY154 Tires: Or <br /> (Licen e Plate) ler ame) Exemption(if applicable): <br /> PC dd,' / 1 C3 Pick up 0 LEA Exempt <br /> t [I Government <br /> Whole <br /> (State l� ` � � ❑ Cubic Yards Govement <br /> (City) l (stale) (zip Code) El Carrier <br /> r(' Q (J--� El Pounds Delivery E] Agricultural <br /> Warne of Reporting Party esa] Signature: <br /> C1 Tons Or <br /> (ifapplicable) N Manifest/CTL form - <br /> Quantity of Check One: / Unregistered Tire hauler <br /> Tires: Or <br /> License Plate (Hauler Name) <br /> ( ) Exemption(if applicable): <br /> (Address) Type of Load: El Pick up ❑ LEA Exempt <br /> (State) Q Whole ❑ Government <br /> (City) (state) (zip Code) ❑ Cubic Yards ❑ Commercial Carrier <br /> ❑ Pounds ❑ Delivery ❑ Agricultural <br /> Name of Reporting Party Decal number Signature: ❑ Tons Or <br /> (if applicable) ❑ No ManifeWCTL form <br /> Quantity of Check One: Unregistered Tire hauler <br /> Tires: Or <br /> License Plate (Hauler N ) <br /> ( ) Name) T Exemption(if applicable): <br /> / e of Load:/ (Address) —� ❑ Pick up 13 LEA Exempt <br /> (State) Whole ❑ Government <br /> (City) (state) (zip Code) ❑ Cubic Yards El Commercial Carrier <br /> ❑ Pounds ❑Delivery ❑ Agricultural <br /> ❑ <br /> Name of Reporting Party Decal number Signature: Tons Or <br /> (if applicable) ❑ No Manifest/CTL form <br /> Quantity of Check One: Unregistered Tire hauler <br /> Tires: Or <br /> (License Plate) (Hauler Name) <br /> Type of Load: Exemption if applicable): <br /> ❑ <br /> (Address) l Whole El Pick up 0 LEA Exempt <br /> (State) <br /> ❑ Cubic Yards ❑ Government <br /> (City) (state) (zip Code) Delivery ❑ Commercial Carrier <br /> ❑ Pounds <br /> ❑ Tons ❑ Agricultural <br /> Name of Reporting Party Decal number Signature: Or. <br /> (if applicable) 1 ❑ No Manifest/CTL form <br /> Please submit this form within 30 days to: CIWMB, Waste Tire Hauler Program, P.O. Box 4025, MS-22, Sacramento, CA 95812 <br /> or fax to (916) 319-7605 <br />