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Static ofCalifomia California Integrated Waste <br /> CIWMB 204(Rev.01/07) Management Board <br /> Unregistered Hauler & Comprehensive Trip Log Substitution Form <br /> Name and Address of Facility: r"` TPI DH <br /> 0 _ <br /> Date&Name License Plate& Hauler's Name/Address/Signature Quantity& Pick up/Delivety Unrevslered Tire <br /> `r Decal Number Type of Tires Status Hauler or Exemption <br /> CD if ap licable) = Status(inapplicable) <br /> cel 2 N 1� Quant" f Check One: ❑ Unregistered fire hauler <br /> lrJ� 7'tres or <br /> J. (Licensee te) (HantttNamd © �� Exemption fifappicablci: <br /> )�Qj Tytx of ..oad: E]of up [I LFA Exempt <br /> 1 I (Address) ❑ Whalt: <br /> State � ❑ Gnvemrturt <br /> ,- l ) - Cubic Yards <br /> .L �'� (cog,) wt ode) ❑ ry ❑ (`nmmerc ial Carrier <br /> r�a�cf`— _ Pounds elive ❑ Agricultural <br /> 41 e of Rtporting Part• Dl rtttntber Tons Or <br /> p g y Decal Signature: <br /> (Kappficabtc) ❑ No ManifestlC:fL furor <br /> Quantity of Checkone. ❑ Unregiste red'fire hauler <br /> rues or <br /> (Licrnse Plate) <br /> (ttaYttr Nemc) Erruipli(m fifatilicable <br /> I (Add,m) Type of Load: [I Pick tip [ILEA Ercmpi ) <br /> El Whale <br /> Cubic Yards ❑ Government <br /> (State) <br /> (Ci,y) (state) (Zips�) ❑ ❑ Commercial Carcier <br /> ❑ Pounds I]Delivery ❑ Agricultural <br /> Nine of Rc ortin P Decal number Ll Tons Or <br /> p g arty Signature: ❑ No b,1antfesUCT1,form <br /> (t appllcabld <br /> Quantity of Clitxk One- Unregistered Tire hauler <br /> ' Tires. or <br /> (LiccuscPlate) (ttsulr w �) <br /> Exemption(if applicable): <br /> I I Inadress) c of Load: [:1Pick up 13 LEA Txpmpt <br /> (State) ❑ Whille <br /> E] Cubic Yards ❑ Government <br /> Pty) (stare) -Tip ❑ ry Delive ❑ Commercial Carrier <br /> [:] Pounds ❑ Agricultural <br /> [3 I Orr; Or <br /> > Name of RSignature <br /> eporting Party Decal number Signare <br /> m (inapplicable) - _ Ll No Manifestr C L form <br /> Quantity or Check Ore: Unrcgistrred Tire hauler <br /> Tires: or <br /> (l iceuse Plate) (Hauler Namc) Hxemptinn(i rapplieul le) <br /> / I Type ofl.nad: ❑Pick up El LFA Exempt <br /> C) (nddast)(State) ❑ Whole ❑ Government <br /> Cl) ❑ Cubic Yards E] m <br /> Cornetetal Carrier <br /> o (cig) tS azq (upcod�) ❑ Pounds ❑Delivery <br /> ❑ Agriculrtral <br /> O ❑ Tum Or <br /> Manic of Reporting Party Decal number Signature: No Mar.ifest/CTL form <br /> Cy) <br /> Please submit 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 />