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■ CA Retread#11& Load- • alifomia Integrated Waste Management Board ■ <br /> PO Box 4025, Sacramento,CA 95812-1259 <br /> �,_-- EXAE 1 2 3 Retread Log Number <br /> MPL <br /> State of Caltfornta - <br /> ClwrxB-1aa(New 03/04)INSTRUCTIONS ON BACK DO NOT TAPE, STAPLE OR DUPLICATEi i1 v 1 Q <br /> Retreader Business Name <br /> Address <br /> City, State, Zip <br /> Decal Number _ License Plate Number DOT - Load 113late(mwDDNY) <br /> Tire Program LF1D-Site Suffix Business Name/Address _ Pickup dmunt Delivery Coup# <br /> Invoice Ndmber �.J U Q 4 ci'Ir <br /> ;- <br /> IU-- <br /> Tire Program 1D-Site Business me/Addresvit Pickup Count "Delivery Count <br /> Invoice Numbers2 �U U ', EN� <br /> Tire Program _.: a <br /> B slness Name/Address Pickup coiir# Delivery Co�iitt <br /> Invoice <br /> 0.,t. '� <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count DeNveXyCc3un# <br /> Invoice Number j '� lvi(�j . �C �t 1 /.,• � i 2 <br /> A Cf <br /> Tire;Program iD-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> . <br /> Inv 9I` .0. i 1A1� � ( , � 1.,: 7 r =-7 <br /> `) i <br /> " p <br /> Tire Program ID-Site _ U " r `.y .-_ f /. I�,—a <br /> Suffix Business Name/Address Pickup Count Delivery Count <br /> Invoice N ` <br /> ber <br /> I certify under pen44 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 /> of renewal of lhP.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. <br /> l , <br /> Z 7 <br /> Driver's,Name (print) Driver's Signature Date <br /> Toll Free 1-866-896-0600 /.WWW-CiWMb.ca.gov/Tires/ &� <br />