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CA Retreader 'a Log California Integrated Waste Management Board <br /> O Box 4025, Sacramento,CA 95812-1259 <br /> E X A M P L E 1�2 31 �_ Retread Log Number <br /> R — <br /> wMe 180(New0=4)INSTRUCTIONS ON BACK DO NOT TAPE, STAPLE OR DUPLICATE 1� O <br /> Retreader Business Name <br /> U U CJ { (!� <br /> Address <br /> City, State, Zip <br /> Decal Number License Plate Number DOT Load Date(MM/oDNY) <br /> [6 F9T,�14- 1 -� �1 R/ E, / <br /> Tire Program ID-Site Suffix E <br /> Business Name/Address Pickup'Count Delivery Count <br /> -]�LLTTTJI vOce Number <br /> EJ, <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count DellveryCount <br /> Invoice Number <br /> L61 <br /> Tire Program ID-Site Suffix Bu ness Name/Address Pickup Count Delivery Count <br /> Invoice .Number <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Delivery:Coui►t <br /> JTF-T-1-T-1 <br /> Invoice Number <br /> Tire Program ID-Site Suffix Business Name J Address _ Pickup Count Delivery Count <br /> Invoice Number �.5 <br /> Tire Program ID-Site Suffix Business Name/Address Pickup.Count DeliveryCount <br /> �`� ; <br /> 1 l <br /> Invoice Number y 111_ <br /> , 1 <br /> I certify under penalty of perjury under the laws 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 /> 3f 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 on <br /> described in Public Resources Code section 42962. t <br /> Driver's Name (print) Driver's Signature Date <br /> 23259 <br /> Toll Free 1-866-896-0600 / www.ciwmb.ca.gov/Tires/ �� <br /> While:CIW MB Copy Yellow:Retreader Ccpy <br />