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California integrated Waste Managhment Board <br /> ;.-M CA Retriiiiiador Trip_Log PO Box 4026, Sacramento,CA 95812-1259 <br /> Retread Log Number <br /> JEJXJA1MJP-T 3] . . i .---- <br /> aim EXAMPLE 11121 <br /> 91218 of CGINGM10 <br /> CIWMB-180(N.owoo INSTRUCTIONS ON BACK 00 NOT TAPE, STAPLE OR DUPLICATE� R 9---, 1 0 5 7 3 11-- <br /> tj <br /> DO N,Ic�:70 <br /> Address" <br /> tAJ <br /> i City.State.Zip <br /> Decal Number License Plate Number DOT Load Date(MM/DDNY) <br /> -T --7 <br /> 0-1 <br /> Rr - iV I <br /> [ J -- i <br /> Tire Program ID-site Suffix Business Namq/Address Pickup Count Delivery Count <br /> e-7 7 <br /> invoice Number <br /> Ls <br /> Tire Program ID-Site Suffi.x Bus,iness Name/Addrelis Pickup Count Delivery Count <br /> r- <br /> Invoice Number <br /> Tire Program ID-SIteSuffix Business Name J Address Pickup Count Delivery Count <br /> ...T. <br /> Inv <br /> pice Number <br /> tk <br /> Tire Program ID Site Suffix Business Name Address Pickup Count Delivery Count <br /> -7-7 <br /> .—J <br /> Invoice Number <br /> Tire Program ID-Site Suffix Business Name if Address Pickup Count Delivery Count <br /> J <br /> 1 <br /> Invoice Number <br /> r <br /> Tire Prog-rim ID-Site Suffix Busine as Name Address Pickup Count Delivery Count <br /> InInvoice Number <br /> I certify under penalty of perjury under the laws of the State of Callornia that the information provided above is true <br /> and correct. In addition,i am aware that falsification of this information may result in suspension,revocation,or denial <br /> of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in <br /> civil penalties up to$25,000 per day,per vinialion or administrative penalties up to$5,000 per vioiation per day as <br /> described in Public Resources Code section 42962. <br /> D <br /> 2(- <br /> " <br /> Driver's Name (print) Driver's Signature Date <br /> 23259 <br /> Toll Free 1-866-896-0600 /WWW.CiwMb.ca.gov/Tires/ <br /> White:CIWMBCopy Yellow Retreader Copy <br /> 2'd 262ee%,:01 S2TR-190 (602) 1 00 3dI1 MM NOS-1IM:W0dJ 0080 S002-ST-Nil!' <br />