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State of California California Integrated Waste <br /> CIWMB 204(Now 3/05) Management Board <br /> Unregistered hauler& Comprehensive Trip Log Substitution Form <br /> Name and Address of Facility' SAN JOAQUIN COUNTY TPID# 1 1098431 - 01 <br /> ROAD MAINTENANCE DIVISION <br /> 1810 E. HAZELTON AVE. <br /> STOCKTON CA 95205 Roadside Collection <br /> Hanler'a Name/Address/Signature Pick up/Delivery Unregistered Tire <br /> Status Hauler or Exemption <br /> _4�� .,_ .� „� tl• v l s� Tl-� <br /> _, Status rif apDlicable> <br /> SAN JOAOUIN COUNTY—ROAD MAINT. "tity. <br /> Check One: ❑ Unre®stated Tire hsufer <br /> (HaulerName <br /> �ccnea Pla11 <br /> te) ) or <br /> (License <br /> ) <br /> 1810 E.HAZELTON AVE. T ve of Load: El Pick up Pxemytion(ifarmlicable): <br /> CA (Address) (� Whole ❑ LEA Exempt <br /> (State)I STOCKTON CA 95205 ❑ Cubic Yarrls ® Government❑ Pounds ® Delivery El Commercial Carver <br /> (City) (State) (Zip) ❑ Tons (to Maim Yard) ❑ Agricultural <br /> Name of Reporting Party Decal Number <br /> (ifepplicable) Signature: <br /> I <br /> 7� SAN JOAOUIN COUNTY—ROAD MAINT. Q�tity of / check One: U Unregiatared Tin hauler <br /> q Tirca: <br /> (license (Hauler or <br /> ✓� 1810 E.HAZELTON AVE. Ttve of Load. ❑ Pick up Excmotion(ifawlicabla): <br /> CA (Address) ® Whole ❑ LPA Exempt <br /> (Stet.) Cl Cubic Yards ® Government <br /> UQMTON CA 95205 ❑ Pound. <br /> (City) (State) (zip) ® DC ❑ Commerrial Camar <br /> Name of Reporting Party Decal Number ❑ Tons (to Mainent.Yard) <br /> d) ❑ Agricultural <br /> (if applicable) Signeture: <br /> 7 9 _�1 OAOUIN COUNTY—ROAD Tire,:Quantity of Check One: ❑ Unrere <br /> egistd Tin hauler <br /> (L.ioanae Plat. (Hauler Name) Tires: r7( <br /> O� 1810 E.HAZELTON AVE. TNve of Load: ❑ Pick up E�a®tion lior <br /> CA (Add-as) ® whole ❑ LEA Exempt <br /> (State) ❑ Cubic Yards ® Government <br /> 1 STOCKTON CA 95205 <br /> 1 l (City) (State) (Zip) ❑ Toned ® DC11VtTY ❑ Commercial Cartier <br /> l•) Yt (to Maint Yard) ❑ Agricultural <br /> ame o .porting Pally Decal Number <br /> (if applicable) Signed".: - <br /> SAN JOAOUIN COUNTY—ROAD MAINT. Quantity of Check One: ❑ Unregistered Tire hauler <br /> (Ucenec.Plate) (Hauler Name) Tires: or <br /> / 1810 E.HAZELTON AVE. TNw of Load: ❑ Pick up Exemotion(ifaoolicable): <br /> CA (Address) 0 Whole ❑ LEA Exempt <br /> (Stat.) ElCubic Yards ® Government <br /> ST TON CA 95205 ❑ PounceCommercial <br /> (Cit) (State) (lip) ❑ Tons ® Delivery ❑ Ap'ieultnssl Carver <br /> Name of (to Maint Yard) <br /> RePm'ting Party Decal Number <br /> (if applicable) Signawn: <br /> Please submit this form to: CIWMB, Waste Tire Hauler Program, P.O.Boz 4025, MS-22, Sacramento, CA 95812 <br />