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State of California <br /> California Integrated Waste <br /> • CTWMB 204(New 3/05) Management Board <br /> Unregistered Hauler & Comprehensive Trip Log Substitution Form <br /> Name and Address of Facility: SAN JOAQUIN COUNTY TPID# 1098431 - O1 <br /> ROAD MAINTENANCE DIVISION <br /> 1810 E. HAZELTON AVE. <br /> STOCKTON CA 95205 Roadside Collection <br /> DatesBt 1Vame r, , i x iicnse 1!later& Hauler's Name/Address/Signature rQiaai�tyH& � Pick up/Delivery Unregistered Tire <br /> ecalGNtr�nber e�Ffire Status <br /> Hauler or Exemption <br /> I><cable" Status(if applicable) <br /> � SAN JOAOUIN COUNTY—ROAD MAINT., Quantity of Check One: ❑ Unregistered Tire hauler <br /> (License Plate) (Hauler Name) Tis q or <br /> / lJ lj 1810 E.HAZELTON AVE. TNve of Load: El <br /> Pick up Exemption(ifannlicable): <br /> (State)CA18 <br /> (Address) ® Whole <br /> ❑ LEA Exempt <br /> STOCKTON CA 95205 ❑ Cubic Yards ® Government <br /> (City) 0 Pounds ® Delivery E] Commercial Cm-ier <br /> Name of Reporting Party Decal Numher p) ❑ Tons (to Maint Yard) ❑ Agricultural <br /> (if applicable) Signature: <br /> 9 6 / SAN JOAOUIN COUNTY—ROAD MAINT. Quantity of � Check One: ❑ Unregistered Tire hauler <br /> (License Plate) (Hauler Name) Tis: or <br /> CA 1810 E.HAZELTON AVE. Twe of Load: ❑ Pick up Exerrmtion(ifanolicable): <br /> (Address) ® Whole ❑ LEA Exempt <br /> (State) ❑ Cubic Yards ® Government <br /> STOCKTON CA 95205 ❑ oun <br /> Pounds <br /> (City) (state) (Z; Delivery ElCorrunercial Cartier <br /> m <br /> Name of Reporting Party Decal Number (City) <br /> ❑ Tons (to Maint Yard) ❑ Agricultural <br /> (ifapplicable) Signature:. <br /> z SAN JOAOUIN COUNTY—ROAD MA11,47 Quantity of Check One: ❑ Unregistered Tire hauler <br /> / O6 (license Plate) (Hauler Name) Tires: or <br /> / CA 1810 E,HAZELTON AVE. T -De of Load: ❑ Pick up Exemotion(ifaoolicable): <br /> (Address) Whole ❑ LEA Exempt <br /> (State) ❑ Cubic Yards ® Government <br /> ON CA 95205 El Pounds <br /> (City)ity) (State) (zip) ❑ Tons ® Delivery Commercial Carver � <br /> Name of Reporting Party Decal Number (to Maint Yard) ❑ Agricultural <br /> (if applicable) Signature: <br /> SAN JOAOUIN COUNTY—ROAD MAINT. Quantity of Check One: ❑ Unregistered Tire hauler <br /> (License Plate) (Hauler Name) Tires: or <br /> 1810 E,HAZELTON AVE. T-De of Load: ❑ Pick up Exerrmtion(if avoli<able): <br /> CA (Address) Whole ❑ LEA Exempt <br /> (State) ❑ Cubic Yards ® Government <br /> STOCKTON CA 95205 <br /> (City) (State) (zip) ED Pounds ® Delivery E] Commercial Carrier <br /> Name of Reporting Party Decal Number p) ❑ Tons (to Maint Yard) ❑ Agricultural <br /> (if applicable) Signature: <br /> Please submit this form to: CIWMB, Waste Tire Hauler Program, P.O. Box 4025, MS-22, Sacramento, CA 95812 <br />