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Toll Free 1-866-896-0600 / www.ciwmb.ca.gov/Tires/
<br />3248742 -= C
<br />Hauler Tire Program ID / Site Suffix I DAT "�
<br />wa Whole Tire Count H Weight in Lb
<br />jA-147 ' • l i 0 Volufne Cubic Yds 0 Weight in Tons
<br />Haul -:r Name
<br />Q? 1!.
<br />Wainer Teiephone Number ]LOO . ..
<br />IN Id.
<br />L r ! Whole TIfD$
<br />r i r
<br />3248742 -- B
<br />Hauler Tire Program ID / Site SuffixIA T E
<br />Hauler Name
<br />i � C
<br />Hauler Telcphonc Numb,:r
<br />3248742
<br />Hauler Tire Program ID / Site Suffix
<br />MM®®®®N�z
<br />Rattler �me .,
<br />l' Q1-,
<br />Hauler Telephone Number
<br />TE
<br />DRE11000-00
<br />Facility Telephone Number
<br />0 00—pnDOE o 0
<br />Address Saline as Haulert _`Initials
<br />I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE
<br />LAWS OF THE STATE OF CALIFORNIA THAT THE !,
<br />IMU p � ❑��0000000-ori
<br />[]jj
<br />Facility Telephone Number
<br />DUD-OUOn, 00F
<br />VVhole Tire Count 0 weight in Lbs.
<br />i c r :ag j U"4
<br />Volurnle Cubir, Y(13.11• -,1 -*, t l
<br />C;i;,, -ip f v f
<br />Ct"`Ts'� j)r l �'� (•li�(J .•1,r u. r ; r + ..I
<br />1 Atrdress Same as Hauler initials
<br />I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE
<br />LAWS OF THE STATE OF CALIFORNIA THAT THE ' -
<br />,ucr.nu.nnu eenv,nen senor: he Tor,C nun r•noOFM t . f _-� -
<br />f„Pick Up
<br />Delive 0 0.0 0 H D 0-0'0
<br />.ir/
<br />Whole Tire Count. uttint.
<br />Voiurne Cubic Yd-,. nWeight in T
<br />=acility Telephone Number
<br />000-0000000
<br />Iii C:1{
<br />�,...X, T'
<br />Address Same 3Aa ICI Initials ftlI
<br />1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE I
<br />1 AWS OF THE ATE OF CAI IFORNIA THAT THE
<br />.,,. CA Comprehensive Trip Log
<br />California Integrated Waste Management Board
<br />and Receipts 10002 P.O. Box 1259,Saeramento,CA95812-1259
<br />E ?;A hiP.L�Eiti21
<br />NA-U-01
<br />_ _..
<br />Comprehensiverehen.sive Trip Number
<br />o32487.
<br />c2zdC6aJar(ronwb INSTRUCTIONS ON BAC OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE
<br />s� _ 2
<br />By9signing this CA Comprehensive Trip Log and Receipt, the signers) request that the Information provided on this forth will be considered confidential, proprietary and trade secret. In accordance with Title, 14 CCR. Section
<br />17041 at seq., If a request Is made for disclosure or this Information, the CIWMB will contact the signer(&) of this form at the address and telephone number provided on this form or receipt.
<br />Vehicle InfdlTnation e
<br />— -- - -
<br />Truck Decal Number, -
<br />Hauler Address
<br />�fs?•t!
<br />Business Name yn/4�� /`1T�/�i ez� �)%r �`
<br />0 0 , ,' ,y-
<br />`
<br />Address
<br />City, State and Zip
<br />License Plate Number
<br />p
<br />Common �C ��J *.,c O/,'f
<br />LCarrier
<br />I cantly under penally of per)ury under the laws of the State of California that the information provided above is We and correct. In addition, 1 am aware That falsificatiomoJlhis information may result in suspension, revocation, or denial of renewal of th
<br />Waste Tire Hauier Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to $ 25,000 per day, par violation or admirye7allw pepa10aEtip to $5,000 per violation per day as desaibad in Pubyc Resources
<br />Code section 42962��
<br />•. —
<br />Driver's Name (print)
<br />'" Dee r's SigtiatureJ at6
<br />3248742 -= C
<br />Hauler Tire Program ID / Site Suffix I DAT "�
<br />wa Whole Tire Count H Weight in Lb
<br />jA-147 ' • l i 0 Volufne Cubic Yds 0 Weight in Tons
<br />Haul -:r Name
<br />Q? 1!.
<br />Wainer Teiephone Number ]LOO . ..
<br />IN Id.
<br />L r ! Whole TIfD$
<br />r i r
<br />3248742 -- B
<br />Hauler Tire Program ID / Site SuffixIA T E
<br />Hauler Name
<br />i � C
<br />Hauler Telcphonc Numb,:r
<br />3248742
<br />Hauler Tire Program ID / Site Suffix
<br />MM®®®®N�z
<br />Rattler �me .,
<br />l' Q1-,
<br />Hauler Telephone Number
<br />TE
<br />DRE11000-00
<br />Facility Telephone Number
<br />0 00—pnDOE o 0
<br />Address Saline as Haulert _`Initials
<br />I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE
<br />LAWS OF THE STATE OF CALIFORNIA THAT THE !,
<br />IMU p � ❑��0000000-ori
<br />[]jj
<br />Facility Telephone Number
<br />DUD-OUOn, 00F
<br />VVhole Tire Count 0 weight in Lbs.
<br />i c r :ag j U"4
<br />Volurnle Cubir, Y(13.11• -,1 -*, t l
<br />C;i;,, -ip f v f
<br />Ct"`Ts'� j)r l �'� (•li�(J .•1,r u. r ; r + ..I
<br />1 Atrdress Same as Hauler initials
<br />I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE
<br />LAWS OF THE STATE OF CALIFORNIA THAT THE ' -
<br />,ucr.nu.nnu eenv,nen senor: he Tor,C nun r•noOFM t . f _-� -
<br />f„Pick Up
<br />Delive 0 0.0 0 H D 0-0'0
<br />.ir/
<br />Whole Tire Count. uttint.
<br />Voiurne Cubic Yd-,. nWeight in T
<br />=acility Telephone Number
<br />000-0000000
<br />Iii C:1{
<br />�,...X, T'
<br />Address Same 3Aa ICI Initials ftlI
<br />1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE I
<br />1 AWS OF THE ATE OF CAI IFORNIA THAT THE
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