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now <br /> State ofCalifomia California lntegraled Waste <br /> CIWMB 204 (Rev. 01/07) Management Board <br /> Unregistered Hauler & Comprehensive Trip Log Substitution Form <br /> N <br /> Q <br /> t TPID# <br /> Name and Address of Facility: J <br /> 1 <br /> < _.f / <br /> 00 , .. y <br /> -.. . .— <br /> N Date& Name License Plate& Hanler's Name/Address/Signature Quantity& Pick up/Delivery Unregistered Tire <br /> Decal Number Type of Tires Status I-Iatller or Exemption <br /> o if app licable Status(if a liable) <br /> N 'G Quantity of Check Onc: [)nregistered Tire hauler I k j' Tires: <br /> or <br /> (License Plate) ttta�iu i <br /> �"c� 7( Exemption Sit applicable). <br /> Tvne of LuuJ: <br /> / <br /> CA ,�as O } �� ❑PICK up �'C'F-A Exempt <br /> (State) r�i � � ❑ Whole ❑ Government <br /> (city") (sate) (i(pc ) ❑ Cubic Yards ❑ Commercial Carrier <br /> 1-, r ! ❑/� Pounds(� _ Delivery ❑ Agricultural <br /> Name of Reporting Party— Decal number y�.; �J Tuns <br /> p g 5 Signature: � � Or <br /> (rapptic.btc) - - ❑ No MatifttiCTL form <br /> 1 _r i Quantity o Chuck One: Unregistered Tire hauler <br /> /� 1v ' h^ �' rites: .ti or <br /> (Lice a late) (Itarlxr ttpmc) [.-- <br /> / F.xem rot ton(!f annl icablc): <br /> 1, <br /> Type of Load: ❑P1ClC tip _A Ftcmpt <br /> (State) 7( ( r �� `7 ❑ Whole <br /> Government <br /> (Gly) sue) (Zip Code) <br /> ❑ Cubit;Yards ❑ Commercial Camcr <br /> ❑ ids X Delivery ❑ Agricultutal <br /> Tons <br /> Name of Reporting Party Decal number Signature. _'- Or <br /> (itappticzbk) ❑ No Manifestit- <br /> form <br /> Quantityof C Check One: ElUnregistered fire hauter <br /> Tires. V� 1 OI' <br /> (License Plate)( (rrxtkr NAHgJ) C � Exern wn rfa licablc)_' <br /> J �- �C [ypc of Load: ❑Pick u EA Fxcmpt <br /> 1�_ (A "call 1 t :I -. ❑ Whole p <br /> (State) 1 ` ❑ Cinvernment <br /> �) (slate) (Zip code) ❑ Cubic Yards ❑ Commercial Carrier <br /> ���, Pounds �Clivety ❑ Agricultural <br /> eme off Reporting Party Decal number Signature: �- _ Totts Or <br /> M ( ,p�C ElNo ManifestlC TL form <br /> m Quantity of Check One: ❑ Unregistered Tire hauler <br /> Fires: Ur <br /> (License Plate) (ttaWerNamel <br /> - eEx trnnption(if�avplicablct: <br /> / (AJdicu) TyIN of Load, ❑Pick up ]FLEA Exempt <br /> n! (State) (A Whole p Government <br /> ❑ Cubic Yards <br /> O (c ly) (s aa•) (zip s arc) Cu ❑ ('ntnrncr0ial('artier <br /> Pounds ❑Delivery ❑ Agricttttural <br /> o Name or Reporting Party Decal number Signature ❑ Time Or <br /> (h (if applicable) ❑ No ManifesVCTL form <br /> '-mit this form within 30 days to: CIWMB, Waste Tire Hauler Program,P.U. Box 4025,MS-22,Sacramento, CA 95812 <br /> or fax to (916)319-7605 <br />