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lifomia Integrated Waste Management Board <br /> CA Retreader Logo Box 4025, Sacramento,CA 95812-1259 <br /> E x A M P L E 1 2 3 Retread nLogq Number <br /> Mof B-;eo California9117ON BACK DO NOT TAPE, STAPLE OR DUPLICATE R 4 ' 1 V 1 �7 <br /> Tire Program ID Site Suffix <br /> U v Pacific coin f ��s�b ���, Im <br /> Phone Number(include area code) <br /> ( ) - Oaklam., -A 94br-i"i <br /> (5101434-1?�6( <br /> Decal Number License Plate Number DOT oad Dae M/DDNY) <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count , Delivery Count <br /> q �p fl 6 �-f � - I kA S V`t 4 <br /> Invoice Number LOO v l f <br /> Tire Progra ID-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> Invoice Number t tJ U V C <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> Invoice Number MIX C <br /> Ifekle-, <br /> v <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> Invoice Number <br /> 2- 3 0,VV Cc, ct c u <br /> Tire Program ID-Site Suffix Business Nam /Address Pickup Count Delivery Count <br /> Invoice Number <br /> 3 S rock 7o i-i Cc, 31� <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> Invoice Number <br /> P\ 0(r-f(eV -- <br /> A . <br /> I certify under penalty of perjury under the laws of the State of California that the Information provi ed above is true <br /> and correct. In addition,I am aware that falsification of this information may result in suspension,revocation,or denial Totals' ' ' <br /> Yrenewal of the Waste Tir Hauler Registration pursuant Public Resources Code section 42960 and may result in <br /> civil penalties up to$25, per day,per violation or ad ' i trative penalties up to$5,000 per violation per day as <br /> 3 � <br /> Jescnbed in Public Res es Codenn 42962. Lo <br /> L4,fl _P � <br /> Driver's Name ( t) vor-s Signature 6ate <br /> 23259 <br /> Toll Free 1-866-896-0600 /www.Ciwmb.ca.gov/Tires/ <br /> W hite*CIW MB Conv Yellow:Retreader CoDV 1 ■ E ■ 1 <br />