Laserfiche WebLink
Mar 15 05 12: 04p Vi - Hamblin 04?41287 p. 4 <br /> Cam,.--ia Integrated Waste Management Board ■ <br /> CA Retreader Tri Log PO Box 4025, Sacramento,CA 95812-1269 <br /> Retread Log Number <br /> EXAMPLE 1 2 3 <br /> w;a�s- f Californiaw03M)INSTRUCTIONS ON BACK DO NOT TAPE STAPLE OR DUPLICATE `i Q y V z <br /> Tire Program ID Site Suffix Retreadefs, loci' <br /> l 0 U r-) 2 � � - () ( itiG C 1269 5r pa. <br /> PhoneNumber(include area code) 081i10d, CA 94621 <br /> } - 5i6) 434-1260 <br /> Decal Number License Plate Number DOT Load Date(MM/DD/YY) <br /> r1l / M 0 � / ,fr / 4�� <br /> 50 cl( Mx. Pickup Count Delivery Count <br /> Tire Program ID-Site Suffix Business Name/Address <br /> 5 / 1n -D C� 2 <br /> Invoice Number C"v ►+�o� I[ �f 3 / 1 `3 9 <br /> Pickup Count Delivery Count <br /> �( <br /> Tire Program ID-Site Suffix Business Na a Address <br /> , <br /> Invoice Number <br /> � � <br /> Tire Progra> Site Suffix T __ .... ___._.._........ Picku Count Delivery Count <br /> Business Name/Address <br /> P <br /> Invoice Number <br /> pickup Count Delivery Count <br /> Tire Program ID-Site Suffix Business Name/Address P <br /> Invoice Number <br /> _----_-----------._._..__.__...._.-._.-_- ..__._______.___—...._.-...____.__-____ _�..._._..__-.- _. Pickup Count Delivery Count <br /> Tire Program ID-Site Suffix Business Name/Address <br /> Invoice Number <br /> ...; Pickup CountDelivery <br /> Count <br /> Tire Prograim ID-Site Stutfix <br /> Business Name/Address <br /> Invoice Number <br /> I certify under penalty of perjury under the laws of the State of California that the information provided above is true <br /> and correct. In addition,I am aware that falsification of this information may result in suspension,revocation,or denial TOWS: <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 7 <br /> described in Public Resources Code section 42962. <br /> Driver's Name (pant) Driver's Signature Date <br /> 23259 <br /> Toll Free 1-866-896-0600 /www.CiWMb.Ca.gov/Tires/ <br /> - Whhe:CIWMB CopY Yellow:Retreader Copy <br />