Laserfiche WebLink
California Integrated Waste Management Board <br /> CnERetreader og �O Box 4025, Sacramento,CA 95812-1259 <br /> XAMPLE p Retread Log Number <br /> : . R3 - 1019116 <br /> ate of California <br /> WMB-180(New o3/o4)INSTRUCTIONS ON BACK DO NOT TAPE, STAPLE OR DUPLICATE <br /> Tire Program ID Site Suffix <br /> L v v v 2 ( (.P — U � pacific co-2-4t Retreaders, Inc. <br /> Phope Number(include area code) 120- 57' Ave• <br /> t _ Oakland, CA 94621 <br /> (510) 434-1�f�0 <br /> Decal Number License Plate Number DOT LoaRate(MM/DDNY) <br /> Tire Program ID-Site Suffix Business 7Nne/Address Pickup Count Delivery Count <br /> Invoice Number <br /> 1 YL � <br /> Tire Program ID-Site ix <br /> Business Name/Address Pickup Count Delivery Count <br /> 1-11�4-5 IP4 C-,,' "j <br /> Invoice Number V S S <br /> Tire Program ID-Site Suffix Business Name/Addr s Pickup Count Delivery Count <br /> Invoice Number �U <br /> Z 2 Z <br /> 0--vv e-1 �.0(eo <br /> Tire Program ID-Site Suffix Business_3me/Addre s Pickup Count Delivery Count <br /> A <br /> Invoice NumberZ'500 � t ., s 3 v 3 <br /> Tire Program ID--Site Suffix Business Name%Address Pickup Count Delivery Count <br /> Invoice Number "-{ 5–(i Vq4(t�c - S _71— L <br /> Tire Program ID-Site Suffix Business Name/Address i Pickup Count Delivery Count <br /> Invoice NumberZ.� 3 x <br /> I certify under penalty of perjury under the laws of the State of California thaf 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 Totals: / (� <br /> of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in <br /> civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as �f <br /> described in Public Resources Code section 42962. <br /> I�w c �L-t <br /> Driver's Name (Print) Driver's Signature Date <br /> 23259 <br /> Toll Free 1-866-896-0600 /www.ciwmb.ca.gov1Tires/ <br /> White:CIW MB Copy Yellow:Retreader Copy <br />