Laserfiche WebLink
i <br /> Co fornia Integrated Waste Management Board <br /> ... <br /> C�EX <br /> Retreader og <br /> • Box Retread <br /> Sacramento,CA 95812-1259 <br /> -••• Retread Lo _ <br /> •�•-• A M P L E 1 23 1um er <br /> .rnia 01910 4 <br /> - <br /> late of California <br /> lWMB-ieo(rtev.o3ro4)INSTRUCTIONS ON BACK DO NOT TAPE, STAPLE OR DUPLICATE <br /> Retreader Business Name <br /> Address <br /> City, State,Zip <br /> Decal Number License Plate Number DOT Load Date(MM/DD/YY) <br /> -3 -) 1 (1 - ---I -.]- -i [ X I <br /> L�41f LL L <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> Li� - LAI �. <br /> Invoice Number <br /> 14 <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> -- <br /> Invoice Number Out) <br /> Tire Program ID-Site Suffix B --- <br /> usiness Name/Address _ Pickup Count Delivery Count <br /> (D. <br /> LE <br /> :D,�- <br /> 11-� <br /> I x <br /> 5--- , - <br /> Invoice Number <br /> t. __ <br /> Tire Program ID-Site Suffix — Business Name/Address Pickup Count Delivery Count <br /> � <br /> T1- <br /> Invoice <br /> Number <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> Invoice Number 61 t-t t.. _ / 2 <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> LA Im <br /> Invoice NumberM�LL <br /> L�-- <br /> I certify under penalty of perjury under the laws of the State of California that the information provided above i5 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. J <br /> lJ . / <br /> Driver's Name (print) Driver's Signature ate <br /> 23259 <br /> Toll Free 1-866-896-0600 / www.CiwMb.ca.gov/Tires/ �l <br /> White:CIWMB Coov Yellow:Retreader Conv <br />