Laserfiche WebLink
state of California California Integrated Waste <br /> CIVVNM 204(Rev.01/0' Management Board <br /> Unregistered Hauler & Comprehensive Trip Log Substitution Form <br /> � prvlG.t' nc: j <br /> Name and Address of Facility: 54 �LcX TP1D# <br /> ZQ� q k2 <br /> � Date&Name License Plate& Hauler's Name/Address/Signature Quantity & Pick up/Delivery Unregistered Tire <br /> N Decal Number Type of Tires Status Hauler or Exemption j <br /> (if applicabic Status (if applicable) <br /> o �s�� QtMiltity of Check One: ❑ Ifuregim red Tire hauler <br /> ct Tins: <br /> (License Plate) fNautcy#�ime) Exemption(if apllieahle <br /> 5 <br /> Z,7/ <br /> 7 f Type of Load;II Whale ❑Pick up ❑ LFA Emmpt <br /> �1 (Addr <br /> (State) ❑ Goreminent <br /> r {r•„yj (Zipc,ode) ❑ Cubic Yards ❑ Commercial Carrkr <br /> ❑ Pounds p(i Delivery ❑ Agriculturat <br /> (Fp'[ Tons Or <br /> Name of Repo ting P Ilu al numbtr Signature: <br /> (dspprcabtcj Q No Ma>,ifesUCTI.farm <br /> I r Quantit�I of_. rr--� Check One: Q Uniegts:ered Tire haulcv <br /> r Tiffs' �? or <br /> _ Lrcense late), (Hauls rJa e) J Exemption IF licahlCY <br /> T w>w ems• ❑Pick up El LEA Exanwt <br /> (Adds <br /> (State) LI Cttbic Yards Commercial Carrr <br /> ❑ Govtmtrtent <br /> f {ci y) (LiPCode) ❑ cr <br /> ❑ Pounds Delivery ❑ Agricidruml <br /> r� Tons a Cr <br /> Name of Reporting Party Decal number Signature; J <br /> (i(apoicabla El leu jtlarifcst'C1 Lform <br /> Quantity or Check One. ❑ Un-utivered Tire hauler <br /> Tires: or <br /> (License Ptatc) (1leiarr Nnme) GXcm t�tinn i If aQnitcbl <br /> r _ Typc of toad: ❑Pick till ❑ LEA Exempt <br /> (� (AM4eesj ❑ Whole <br /> (•_rate} - __� ❑ I orri xicint <br /> (��) Isarc (x erne) ❑ Cubic Yards ❑ Cumnurcial Carrier <br /> v ❑ Pounds ❑Delivery ❑ Agricultural <br /> [I Tons OrNoof Repurting Party Decal number Signature: <br /> prrpplicabta) El <br /> No MndfcstCTl.form <br /> m Quantity of Check One: E] Unregistered Tim hauler <br /> m Tires: (X <br /> (License Plate) tNaukrName) Nae[n aicahle <br /> {Address) BPI;:of Load: ❑Pick up F1LEA F.Kenip: <br /> ate ❑ Whole <br /> St ❑ Govemanent <br /> N <br /> pate) [ICubic Yards Commercial Catrin <br /> (N (City) Gera, (Zip Code) ❑ Prmnds ❑Delivery ❑ <br /> (r) i ❑ Agricultural <br /> O ❑ Tgns Or <br /> Name of Reporting Party Decal nutubcr Signature: <br /> Q (ifappImsble) ❑ No N9aufcsbC*TL form <br /> C0 Please submit this form within 30 days to: CIWMB,Waste Tire Hauler Program,P.Q.Box 4025,MS-22, Sacramento, CA 95812 <br /> or fax to (916) 319-7605 <br />