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i <br /> State of CaliforM2 California Integrated Waste <br /> CN.'.%•tB 204 (New 8:05) _iaaagemmll Board <br /> Unregistered Hauler & Comprehensive Trip Log Substitution Form <br /> L <br /> m { FOOTHILL SANITARY LANDFILL <br /> Name and Address of Facility. 6484 N4 WA[�ERLY-RD. TPID# 1 ii 0 7 0 0 9 0 1 <br /> m 4 <br /> m l LINDEN, CA 95236 )! <br /> t <br /> .-� i • <br /> m <br /> Date &Name License Plate& I Hauler's Name!Address.'Signature Quantity& Pick uplDelivery 'Unregistered Tire <br /> a Decal Number { Type of Tires i Status Hauler or Exemption <br /> if applicable) i S (i; licable) <br /> 8�y`r� r � /� p' /►� Quantityof 1 Check Ona: nregistered Tire hauler <br /> Tires:_ 2� I I OT <br /> (tacense Plate) (Muirr Nam) _ j <br /> 11 �" e - A&i)e � T of E�ltion<ifanoaicable?: <br /> 7 C1 _ (ne�e,i) U,-zole c Pick up l Q LEA Exempt <br /> (State] /nJ �-� 9J�3& l ❑ Government <br /> r` I i ❑ Cubic Yards <br /> CD �^y I (City] (s-.Mc (Zip Codi) �,,( ❑ Commercial C'arrler <br /> Barre irein _ ❑ Pounds 2,1.tiellvery ❑ Agricultural <br /> 03 <br /> Name o`Re'porting Parte Decal ntsrsber ! Signature: :. ❑ Tons 5 Or <br /> ffapplxable) i ❑ No Manifest/CTL:a m <br /> + <br /> (1ua:.ttry ct :'rick uae* �l.�nre�,stereo ;::e Muie,- <br /> VO f t I^ �Ei (` C OT <br /> ��^pTires: /0 <br /> tiLicensePlatei ( > Sf <br /> y Exams tption(if auplicaElej: <br /> 1 e?�;' IL_ ( r T rLead: ❑Pick up e LEA Exempt i <br /> Whole ❑ Gove nment <br /> X G Cubic Yams <br /> Q (cn�9 (srae) (zip Cok. ❑ Cort menial Carrier <br /> Lt_ —�?arfdffl C Pounds 9belivery Cl Amriculturzl j <br /> Narx of Reporting Pany Decal number i Signature: �^ ❑ Tons OT <br /> (ir r ) ❑ <br /> No Manlfest/CTL:otm <br /> Quantin of Check One: Lj Unregistered Tice Fzuler <br /> i ;ires: Or <br /> ((.:cense Pluel Exe^sption(if appi csb?el: <br /> j T��Lof Laadr <br /> (Arai.) O Pick up II LEA Exempt <br /> {State) i Q Whole ❑ Government <br /> (City) ism.: 179PCO&j ❑ Cubic Yards ❑ Comrmcial Carriq <br /> ❑ Pounds ❑Delivery <br /> ❑ Tons [3 AgricuiGtral <br /> r_rre n Remrting Pany Decai number Sigrauue: Or <br /> (iraq,llwxi ❑ No ManifestfCTLform <br /> Quart6ty of Check One: Unregistered Tire hauler <br /> Tires: or <br /> (License Pip tel j (mkt Nu' j <br /> t � l�rl�pNan�f a licablel: i <br /> I Tyne of Load- <br /> s' (Adidrmsl Q ote ❑Pick up II LEA Exempt l <br /> (state) El Government t <br /> i (City) tec <br /> S : (ZiFCodcj I ❑ Cubic Yards <br /> ElPounds ❑Delivery ❑ CammerLiai Carrier <br /> ❑ Toils ❑ Agriculturat <br /> Name of Repartirg Pa-y Deca:number 1 Signature: Or. <br /> (ii tgplio6tc) 1 ❑ No Manifest/CTL form <br /> LL Please submit this form within 30 days to: CIti�rMB, Was Fire Hauler Program, P.O. Box 4025, SSS-22, Sacramento, CA 95812 <br /> nr fax to (9161319-7605 <br />