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__•- �� 0-Y-, J........... <br /> V,VI"1 JJV IL-ILJJ <br /> ■ °-.'e`ee, EXAMPLE 1 2 3 Retread Log Number <br /> �R 9 . 1 0 � 9039 <br /> wneteo(Now0=4IINSTRUCTIONS`ON BACK DO NOT TAPE. STAPLE OR DUPLICATE <br /> i <br /> Retreader Business Name <br /> f - 1 <br /> 1 <br /> Address <br /> City, State,Zip <br /> Decal Number License Plate Number DOT Load Date(MM/DDNY) <br /> F-1 R/I Vj ,]]r L,--, <br /> I Fj <br /> fire Program lD-Si#e S�t�tlac _. .. Business Name/Address Pickup.Count Delivery.Count <br /> LF <br /> Invoice Number t <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count : Delivery Count <br /> - <br /> Invoice Number ? V <br /> r <br /> Tire 0064rataf . . f e U. <br /> ~ l slivery Count <br /> Invoice Number <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> Invoice Number i. U <br /> 1�{ 0 <br /> Tire Prdgram ID-Site 5iii i Business Name/Ad ress Pickup Count Delivery Count <br /> (ILL <br /> �.. ce.Number , i 3 <br /> Tire Program ID-Site Suffix Business Name/Address Pickup Count Delivery Count <br /> Tr Tj <br /> Invoice Number - i I-- <br /> certify under penalty of perjury under the laws of a State of California that the information provided above is true <br /> correct. In addition,I am aware that falsification of this information may result in suspension,revocation,or denial r <br /> �f Illi W of the Waste Tire Hauler Registration Orsuant to Public Resources Code section 42960 and may result in l <br /> Jvil penalties up to$25,000 per day,per violatiorpbr administrative penalties up to$5,000 per violation per day as <br /> fescribed in Public Resources Code section 422. fizz <br /> -A <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 Copy ® . <br />