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_ California Integrated Waste Management Board <br /> CA Retreader 09 Box 4025, Sacramento,CA 95812-1259 <br /> ...... <br /> EXAMPLE 1 2 3 c _Retread Log-Number <br /> tate of California - <br /> IWMB-180(New osio4)INSTRUCTIONS ON BACK DO NOT TAPE STAPLE OR DUPLICATE 10 <br /> Retreader Business Name <br /> c) o V t Address <br /> City, State,Zip <br /> Decal Number License Plate Number DOT Load Date(MWDDmr) <br /> I � 4 6 k1 <br /> Tire Program ID-'Site Sufflx ��.{(Bujsiness Name/Address <br /> Pickup Cogn Delivery Count <br /> Invoice Number <br /> c <br /> Tire Program ID-Site Suffix Business Name/Addres Pickup Count Delivery Count <br /> n <br /> El-m W l U Y%\ �`/tet (� r <br /> Invoice Number l v u J 6 O vI& r 1,/ <br /> L4 C- <br /> Tire Program ID S[te Suffix Business Name/Address Pickup Count Delivery Count <br /> Invoice Ntimtier --- 1ct C1 ,�- <br /> I / <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> Invoice Number <br /> F c) <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> YM LI <br /> Invoice Number <br /> Tire Program ID-Site Suffix Business Name/Address V, Pickup Count Delivery Count <br /> 6 JL <br /> Invoice Number <br /> I certify under penalty of p6jury under the laws of the State of Califomia th2t the(i9rnLa f provided move 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 <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. iL . <br /> II <br /> Driver's Name (print) Driver's Signature Date <br /> 23259 <br /> Toll Free 1-866-896-0600 / WWW.CiWMb.ca.gov/Tires/ <br /> White:CIWMB Copy Yellow:Retreader Copy <br />