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State of California California Integrated Waste <br /> Management Rnard <br /> C!W MB 204(Rev.01/07) <br /> Unregistered Hauler & Comprehensive Trip Log Substitution Form <br /> t� <br /> Name and Address of Facility: �, -�,�,5�,'n �c11 TPID# o <br /> 0 <br /> 04 <br /> Date&Name License Plate & Hauler's NamelAddress/Signature Quantity& Pick up/Delivery Unregistered Tire <br /> Dccal Number Type of Tires Status Hauler or Exemption <br /> C3 (if a licable Status(if applicable) <br /> QuAnr of j Check Onc ❑ Unregistered Tire hauler <br /> 4 <br /> n c >I ires: l' �` or <br /> (License Platc) (tim,lrr r e) Rxelnl llnn[ifnolo icrble): <br /> �� D 6 TYp a L.4� ❑Pick up ❑ LFA Exempt <br /> L_L� (A re ! �I 7 I ! ❑ %"Ole ❑ Government <br /> (State) C� ` ❑ Cubic Yards <br /> � <br /> (CirYl nte) (Zip Code) El CommetetalCarricr❑ Pounds OODelivery ❑ Agricultural <br /> t <br /> r�Tons Or <br /> Name of Reporting Parry Decal number signalprc: !! [] No ManifesdC'I'1,form <br /> Quantity of Chcok 011e. ❑ Unregistered Tire hauler <br /> Tires: or <br /> (LicenscPlate) (tuulaNamd f;xemution(if applicable): <br /> TVpe of Load. ❑Pick up ❑ LEA F.xcmpl <br /> (Addicn) ❑ Wbule ❑ Government <br /> (State) ❑ Cubic Yards ❑ Commercial CAnier <br /> (Ciryl (State) (Z, Code) <br /> ❑ Pounds ❑Delivery p ;4ariculturat <br /> _ ❑ Tons or <br /> Name of Reporting Party Decal member Signature: _ ❑ No ManifLOCTL form <br /> (it applicable) rQuwltity2 Check One ❑ Uiuegistered Tire hauler <br /> or <br /> (License Plate) Exemption Gra tU <br /> oad. ❑Pick up 0 LEA Exempt <br /> (Address) e ❑ Government <br /> (State) ❑ Cubic Yards <br /> (Ciryl (state) (�pC°`t`) Relive ❑ t-ntnmcn:ialCarrier <br /> E] Pounds ❑ ry E] Agricultural <br /> _ ❑ Ton; Or <br /> > Name of Reporting Party 'Decal number Signature: ElNo ManifcsdCTL form <br /> m (if applicUnregistered Tire hauler <br /> Tires or <br /> (Lice Exemotionlif <br /> nsePlate) lH"'erN"�) applicahlc): <br /> Q Tvvg of Load: ❑Pick up 0 LEA Fxcmpt <br /> Ce) / / (Adan:t) j] Whale <br /> N ❑ Government <br /> cN (State) ❑ Cuhicyards ❑ Commacial Carrier <br /> o tcav) (snu) stip Cade) [I Pounds <br /> ❑Delivery <br /> ❑ Agricultural <br /> 0) _• ❑ TunsCD Or <br /> Y Signature: <br /> � Name of ReportingPart Dcc;al number � ❑ No ManifdStJCfL form <br /> O li wlicab�e) <br /> Please submit this form within 30 days to: CIWMB,Waste Tire Hauler Program,P.O. Box 4025,MS-22, Sacramento,CA 95812 <br /> or fax to (916)319-7605 <br />