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State of California Califomia Integrated Waste <br /> CIWMB 204(Rev-01!07) Management Boatd <br /> M Unregistered Hauler & Comprehensive Trip Log Substitution Form <br /> a <br /> Nalene and Address of Facility: Cj��_� �� � �.� TPID# ) `' !' <br /> 00 <br /> , <br /> C\1 <br /> Date&Name License Plate& Mauler's Name/Address/Signature Quantity& Pick up/Delivery Unregistered Tire <br /> 6Decal Number Type of Tires • Status Hauler or Exemption <br /> if a I' able) _ <br /> StatUS(if applicable) <br /> ��CII Quantity of ( Check Oae. Unregistered Tire hauler <br /> Tires: l° T or <br /> (License Plate) ("Awq Nene) r Lxcn ption(if 3yplicablel <br /> Tyne of load: ❑Pick up f,4,LEA Exempt <br /> 1 / (Addy� Whole <br /> (State) L f5-Y , C f 1 f r Cubic Yards ❑ GovernmentC <br /> tz,p Codo1 ❑ � ❑ Commercial Carrier <br /> Pounds elivery ❑ Agricultural <br /> Name of Reporting Party Decal number Signature: /.k <br /> ` (irappu,wo - ❑ No klanifestiL11 form <br /> Quantil Check one. ❑ Untegistered"lire hauler <br /> Tires: Or <br /> {License late) tH' .me) rf --� Excm tion if o i licahlei: <br /> R `vof ie a El Pick up EA Exempt <br /> (Blatt) <br /> (ci,yl tel ilip(ude) © CbYards ❑ GCnomvemruemrceiacrlt <br /> Carnet <br /> El.1`01111M <br /> Cll'VCry ❑ Agricultural <br /> ns Or <br /> Name of Reporting Party Decal number Signature <br /> (irapp�; til ❑ No MantfesttCTL form <br /> ,�-•r — Quandt o Check One: Unregistered Tirc hauler <br /> C fires: t or <br /> r (Lieeps (tr" - Exejjlption of anpllcabiel: <br /> ✓1 /�� Aox TvpeM load: ❑Plck up f 2 A Exempt <br /> lAad,ssl h ❑ Whole ❑ Gorernment <br /> (State) 0 1 CA Cubic Yards <br /> tc•itil (st,ir` tiipCode) ❑ Commercial Carrier <br /> E] Pounds eliVCry ❑ AgricuUal <br /> > i <br /> pp ame of Reporting Party Deeal number rrariuc: I�"Pons Or <br /> JJ apphcobkl Sig ❑ No Manife3ti'CI'L Turn; <br /> r-- Quantity of Check One: ❑ llmcgistercd Tire hauler <br /> • — �-i — Tires' _��r. or <br /> Q (Lice c Plate) lySu a Nanic 1 Y E.xen ition if li . l <br /> N (}fes jt T of d: Li Pick Up EA Exempt <br /> f v I (state) <br /> (Ad] <br /> ss1 �, u Whole C]h <br /> Gvern <br /> oment <br /> CD <br /> 1 ( te) [1Cubic Yards <br /> 0) J / t - Wity) tel tz,pC�) E] Cawnere:alCarrier <br /> C) 11 Meanies \Delivery <br /> Tons <br /> t ❑ AFricultw:rl <br /> O Name of Reporting P weal number Signature: Or <br /> (a appeu61c) ❑ Nn Manifest/CTL form <br /> Please submit this form within 30 days to: C1WMB,Waste Tire Hauler Program, P.O.Box 4025,MS-22, Sacramento,CA 95812 <br /> or fax to (916)319-76M <br />