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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 l l 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 /> if applicable) StAtUS (if applicable) <br /> 6 � i Quantity of Check One: Unregistered Tire hauler <br /> ` Tires: Or <br /> /lll�JJY(lDy (Lise Plate) (x° � \4 Exemption f applicable): <br /> V Tvoe of Load: R—� pp <br /> (Adore: �` ❑ Whole ❑ Pick Up ❑ LEA Exempt <br /> (State) <br /> PA— �D ❑ Government <br /> ❑ Cu is Yards <br /> (City) - (state) p Code) ED Commercial Carrier <br /> ounds Delivery ❑ Agricultural <br /> Name of Reporting Part Decal number Si <br /> Tons Or <br /> p g y Signature: <br /> (if applicable) ❑ No Manifest/CTL form <br /> ^t <br /> Quantity off �/ Check One: Unregistered Tire hauler <br /> S� Tires:7 b <br /> Or <br /> Licen a Plate (HaulerN�n <br /> /`� / / ( C /J _) Type of Load: Exemption e p hal: <br /> L/ C L C �° i-r' (Address).- � ❑Pick Up LEA Exempt <br /> /' �• N-Cubic Yards Government <br /> ❑ <br /> (State) El <br /> (c;ty>"" tate (tip Code) ❑ Commercial Carrier <br /> A. - ❑ Pounds [yDelivery ED Agricultural <br /> Name of Reporting Party Decal number Signature: Tons Or <br /> (if applicable) / ❑ No Manifest/CTL form <br /> / <<� Quantitv of Check One: nregistered Tire hauler <br /> (CR4 �)D 1" \ [1�-1•�� F- (`.` Tires: or <br /> (License Plate,) ( a�a C) _ <br /> � �c Exemption(ifa licable): <br /> j 7C-) t�=C� (L: 1_����'►t 'l l� Type of Load: EPP <br /> 7 /�-(�/(�� � cAddress) El up ❑ LEA Exempt <br /> C -Whole <br /> (State) r,, KibaLC- V f"k 155(r( ❑ Government <br /> (city ❑ Cubic Yards <br /> (stare) (Zip Code) El Commercial Carrier <br /> ,- ��'� ❑ Pounds delivery <br /> 1� _ �/ El Agricultural <br /> Name of Reporting Party Decal number Signatur . �- [3 Tons Or <br /> (if applicable) ❑ No Manifest/CTL form <br /> Quantity o Check One: lwunregistered Tire hauler <br /> (o A Tires _ or <br /> / <br /> (License Plate) (Hou rName ��� /' Exemption Exempt applicable): <br /> � a ' ❑Pick up ID LEA Exempt <br /> (Ad s) V 5 Whole <br /> (State) ❑ Government <br /> ❑ Cubic Yards <br /> (city) (state) (Zip code) Commercial Carver <br /> ) / U(�✓ �/ ❑ Pounds [Delivery <br /> . ❑ Agricultural <br /> Name of Reporting Party Decal number Signatur ons Or <br /> (if applicable) ❑ No Manifest/CTL form <br /> Please submit this form within 30 days to: CIW B, Waste Tire Ifauler Program, P.O. Box 4025, MS-22, Sacramento, CA 95812 <br /> or fax to (916) 319-7605 <br />