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state of California California Integrated Waste <br /> CIWMB 204(Rev.01107) Management Board <br /> Unregistered Hauler & Comprehensive Trip Log Substitution Form <br /> CL <br /> Name and Address of Facility: t, �5�"n ���X TPID4 <br /> q� ,��, C ct 533 <br /> 00 <br /> N Date&Name License Plate& Hauler's Name/AddreWSignature Quantity& Pick up/Delivery Unregistered Tire <br /> Decal Number Type of Tires Status Hauler or Exemption <br /> o i.f app licabke Status(if apphcable;� <br /> v <br /> 196B <br /> Quailtit o Check One: [IUnregistered"I've hauler <br /> Jy �dC1�� �nr Tires: or <br /> (Liceacse Plate) (tta,t aroc) r <br /> "7 fxcntpttanjf anpl icahlc l <br /> f) (Ad��9) ` Type of Load: ❑Pick up LEA Exempt <br /> r t (State)— �S�� I L] Whole Govcmment <br /> (City) me) (Zip Code) ❑ Cubic Yards © Commercial Carrier <br /> ❑ Pounds ellvery ❑ Agricultural <br /> );am of Reporting Party Decd cumber Signature: Tons Or <br /> of applicable) ❑ No klanifesdCTL form <br /> �` (2uandty of Check One. El Unregistered Tire haat-1 <br /> l 1�-r Tires:��� Ot• <br /> _ I.icertse Plate) on(tf ]ol cable) <br /> rCQ _ Type of I.oaJ: <br /> I�� (A r - ! 4? ❑Pick up �A Exempt <br /> (state) )' i ❑ Whole <br /> r l El Government <br /> (City) (sats) (rpr.W)r.) ❑ Cubic Yards ❑ CommetciatCarrier <br /> r " ❑ Pounds <br /> ETou KDelivery ❑ agricultural <br /> of Reporting P Decal number Signature Or <br /> (;ta:yiicaWcl ❑ No ManifestTTL form <br /> ' l Quanti L— �Chcck 0nr: [I Unregistered Tim haulerllni <br /> �(�., or <br /> t! � 1 (License Plate) vas" Exe lion ifa liea6l <br /> (A( ? 1 TYPc of Load: ❑Pick up LEA Exempt <br /> (state) 7-j _ �C_ / a Whole ❑ Government <br /> (City) ak) (ZipCnde) ❑ cubic Yards <br /> C' f Pounds Delivery ❑ Commercial Garrinr <br /> 'k] Tons ❑ !+griulttual <br /> Name of Rxpurtirig Party Decal number Signature: Or <br /> N (ifappticabk) - ❑ NoManifestJCTLform <br /> pp - Quantity of Check One; ❑ Unregistered Tirc i auks <br /> Tires: or <br /> (License Plate) (FtaulerAloma) Exe tion ifa tic#to <br /> CL I I (Address) Tvpc of Load ❑P ick up Llf EA Exempt <br /> N (state) ❑ Wholc ❑ Government <br /> n! - ❑ Cubic Yards <br /> (City) (Star) (zip code) ❑ CommercialCarrta <br /> (h ❑17C1t VGry <br /> � ❑ Potmds <br /> El Tons [3Agriculttual <br /> 0O Natne of Reporting Party ^Decal number Signature: Ur <br /> (irapptieabie) I I I 1 0 No ManifeWC71.farm <br /> C3 Please submit this form within 30 days to: CIWMB, Waste Tire Hauler Program,P.O. Box 4025, NIS-22, Sacramento,CA 95812 <br /> or fax to (916) 319-7605 <br />