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WB' <br /> Integrated Waste Management Board <br /> CA Retreader * kog ,WBox4025, Sacramento,CA 95812-1259 <br /> E X A M P L E 1 1 , 2 3 Rettead Log Number <br /> ate of California•� -- - -- - 1019040 <br /> I - <br /> WMB-180(New o3to4)INSTRUCTIONS ON BACK DO NOT TAPE STAPLE OR DUPLICATE <br /> i <br /> i Retreader Businass Name ` <br /> Ad ss <br /> City, St. Zip <br /> DWAT-Number ' License 'Plate Number / DOT Load Date(MM/DD/YY) <br /> i I,` Lcl) --b <br /> Tire Program ID Site Suffix Business Name/Address . Pickup Count Delivery Count <br /> Um <br /> Invoice Number. <br /> G <br /> Tire Program ID-Site Suffix Business siness Name/Address Pickup Count Delivery Count <br /> [T <br /> T1- S �,} i - <br /> Invoice Number t i t>>� r ./ ; r r, <br /> {Tire Program ID-Site suffix ' k Business Name/Address Pickup Count Delivery Count <br /> Invoice Num !H�R <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> lol <br /> t <br /> Invoice Number <br /> I <br /> 7vrbtogram .,'Business Name/Address Pickup Count Delivery Count <br /> L L Q �- ► I _i�_ I �`I I j � - i— <br /> Invoice Num6rcto <br /> -}... _ . <br /> Tire Program ID-Site Suffix Business Name/Address , rPickup Count Delivery Count <br /> FTT I <br /> Invoice Number ` <br /> 1-4 t l tom` <br /> certify under penalty of perjury under the laws Vthetatef California that the information provided above is true <br /> and correct. In addition,I am award that falsification of is information may result in suspension,revocation,or denial - <br /> 3f renewal of the Waste Tire Hauler Registration pursu to Public Resources Code section 42960 and may result in, <br /> :lull penalties up to$25,000 per day,per violation or adm istrati7*alties up to$5,000 per violation per day as <br /> Jescnbed 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/Tjlres/ `�— � <br />