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CA Retreader•� og ifo Bo Integrated Waste Management Board <br /> • Box 4025, Sacramento,CA 95812-1259— <br /> E X A M P L E 1 2 3 Retread Log Number <br /> R9 - 10191051 <br /> tate of CaiHornia 9 - <br /> �" " I <br /> rWM13-1ao(New e3104)INSTRUCTIONS ON BACK DO NOT TAPE, STAPLE OR DUPLICATE: y <br /> Retreader 14"ness Name <br /> U Address <br /> City,State,zip' <br /> Decal Number License Plate Number DOT Load Date(MM/DDNY) <br /> R/[T/ ' [&?] / <br /> [Q-:��tstT)l +A <br /> Tire Program iD-Site Suffix Business Name/ _ Pickup Count ., Delivery ount <br /> tl <br /> ce Number V L:• <br /> fA <br /> Tire-Program ID-Site Suffix Business Na Ad ss a ___.� ickup Count DeliveryCount <br /> UP <br /> Invoice Number Ute: , j.. '•� �` �'-�: f �T� '; <br /> _ � r�l'�f c �- `-•--� • X14 tr <br /> Tire Program ID--SiteSuffix . . Business Name/Ad ess Pickup Count Delivery Count- <br /> ,_...__ <br /> , <br /> Invoice N <br /> Uogram-e-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> F1-T1- <br /> Invoice number <br /> Tir'e.Program 1t>!;-Site.Stt a, Business Name;/Address ,_ Pickup Count Delivery Count <br /> =CT-1 I <br /> Invoice Number ---- ---- ( �v *� ►' ' , �, , ., �1 L <br /> { 51 <br /> Tire Program ID-Site Suffix Business Name/Addres - Plckup Count Delivery Count <br /> Invoice NumberF-i <br /> L4 <br /> ` { r <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 /> 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. t <br /> Driver's Name (print) Driver's Signature z' Date <br /> 23259 <br /> Toll Free 1-866-896-0600 / www.ciwmb-ca-9ov/T1res/ �� <br /> While:CIW MB Copy Yellow:Retreader Copy <br />