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lifom,a Integrated Waste Management Board ■ <br /> . CA Retreader og Box 4025, Sacramento,CA 95812-1259 <br /> 8. <br /> E X .AMPLE 1 2 3 f� Retread Log Number <br /> R. <br /> aie of California •- ' - 1 O ",('} 9 1 2' /� <br /> Y <br /> WMB-1ao(Now.03104)INSTRUCTIONS ON BACK DO NOT TAPE, STAPLE OR-DUPLICATE1 <br /> Retreadereffb"Chst FletreaderS, Inc. <br /> address 1260 UP Ave. <br /> City, State,zip Oakland, CA 94621 <br /> (510) 434-1260 <br /> Decal Number License Plate Number DOT Load Date(MMioorrY) <br /> 4e- R/ ojv---1 5 <br /> L(d <br /> Tire Program ID-Site Suffix Business Name I Address Pickup Count Delivery Count <br /> J <br /> Ei i I 1—,M 1 I / <br /> 1_nvolce Number <br /> 1 - 1 '..' ill _� C c-I <br /> 1 1; [/J L <br /> 3 Cf J J <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> _1 LH, I I EU <br /> Invoice Number <br /> i <br /> 00 o rAq 1 0-I 10C.1 L, <br /> Tire.Prografm ID.-S�ffix Business Name/Address Pickup Count Delivery Count <br /> Invoice Number 4 uu u <br /> I <br /> Tire Program Ib-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> I' <br /> Ivo— /7 � 1c�!e <br /> LL <br /> Tire Program ID Site Suffix Business Name/Address Count aw ,DellveryCount: <br /> .'MJ N r r <br /> Invoice Number <br /> { 4r <br /> Tire Program ID-Site Suffix Business Name/Address Picitu Cotant Delrvft <br /> ►:Couirt <br /> __T_FTTTFP_ <br /> _ f <br /> Invoice Number �✓ <br /> I certify under penalty of perjury under the taws of the State of California that the information provided above is true <br /> and correct. In addition,I am aware that falsification of this information may result in suspension,revocation,or denial <br /> of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in i <br /> civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as <br /> described in Public Resources Code section 42962. <br /> 1 <br /> Driver's Name (print) Driver's Signat re Dat <br /> 23259 <br /> Toll Free 1-$66-896-0600/ www./ciwmb.ca.gov/Tires/ �� <br /> White:CIWMB Copy ' Yellow:Retreader Coov <br />