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Mtr 15 05 12: 03p 'i Hamblin 04341287 p. 2 <br /> LO Ca, !Integrated Waste Management Board <br /> idCA Retreader Tr g PO Box 4025. Sacramonlo,CA 95ai2-1259 . <br /> EXAMPLE 1 2 3 Retread nLogg Number �y <br /> w tes m o3")INSTRUCTIONS ON BACK DO NOT TAPE STAPLE OR DUPLICATE R 2 - 1 V t 9 0 3 L <br /> Tire Program ID Site Suffix pacific Co-St Retreaders, Inc. <br /> t C) CJ 2 C) 1260 5711 Ave. <br /> Phone Number(include area code) Oakland, SPA 94621 <br /> - (510) 434-1260 <br /> Decal Number License Plate Number DOT Load Date(MWDDIYY) <br /> Tire Program ID-Site Suffx Business Name/A dress Pickup Count Delivery ount <br /> Invoice <br /> Number (f C�� a V7�� VILAv <br /> t _....._. . _. .....,..,. . <br /> Tire Program ID-Si suffix Business Name/ dress Pickup Count Delivery Count <br /> Vu �A <br /> Invoice i Number � V <br /> _-- <br /> rog <br /> Tire P ram ID-Site Suffix Business Name/Address Pickup Count Delivery un <br /> S <br /> Invoice Number U v , V <br /> z 3 <br /> Tire Program ID-Site Suffix Busin�e)ssf Name/Address Pickup Count Delivery Count <br /> Invoice Number 1 y l�( ci q ey S \ V 1 C1 v <br /> --- ... _.__..._.__.. �... -�.. ........_......._.___._............�.- - - - - ---- _ _-- ----- <br /> Tire Program ID-Site Suffix Business Name/Addr6ss Pickup Count Delivery unt <br /> v <br /> Invoice Number <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> �Woice Number <br /> i <br /> t-cts*under penalty of perjury under the laws of the State of Caffomia that the information provided above is true <br /> and correct. In addition.I am aware that taisification of this information may result in suspension,revocation,or denial Totals' <br /> of renewal of the Waste TireHaubr 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 s5,000 per violation per day as , 7 <br /> descnbed in Public Resources Code section 42962. <br /> ,ham a 17- <br /> Driver's <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:CIWMBCopy Yellow:Retreader Copy IIS P d <br />