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[--Igomia Integrated Waste Management Board <br /> CA Retreader Og )Box 4025, Sacramento,CA 95812-1259 <br /> E X A M P L E Retread Log Number <br /> I- IIIIIII1 2 3 C - -- - <br /> -------------- <br /> ;tateofCatiforniac i - F- - 1-_0--1_9 1-_.0-_1. <br /> �J <br /> :fWM13-1eo(New o3W)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 /> Tire Program ID-Site Suffix Business 1Yame:f Address Pickup Count, ' Delivery Count <br /> FTT_1__ I <br /> Invoice._Number (UU li <br /> r CtIL <br /> Deli <br /> Tire Program ID-Site Su ix Business Name/Address �. - ``Pickup Count very.Count <br /> m -rim t 1 u <br /> Invoice Number / <br /> U'll� 1 �L <br /> blil Program fD-tIte-Sufflx Business Name 1 Address Pickup Count Delivery Count <br /> Invoice Nuinbet / -1 1 _ `t L� `.' 477 <br /> ... <br /> Tire Program ID-Site Suffix ` Business Name/Address � _ Pickup Coun# Delivery Count <br /> ��j_-�_ -CZE /t3�� s s ��{ 'r <br /> Invoice Number U � <br /> "fire Program ID-Site Suffix Business NameCI /gddress — Pickup Count Delivery Count; 4; <br /> Invoice Number U V <br /> _ <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> tsi ' <br /> 1 5 <br /> Invoice Number <br /> —_--- <br /> ry C <br /> I certify under penalty of perjury under the laws of the State of California that the information providedis true <br /> and correct. In addition,I am aware that falsification of this information may result in suspension,revocationabove,or denial 1124 <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. / <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:CIWMB Copy Yellow:Retreader Cow <br />