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Toll Free 1-866-896-0600 / www.ciwmb.ca.gov/Tires/ <br />California Integrated Waste Management Board <br />CA Comprehensive Trip Log and Receipts 10002 P.O. Box 1259, Sacramento, CA 95812-1259 <br />FE X A M P, L E I; 2 3 ■ Comprehensive Tri Number <br />:,... <br />0W."M= <br />CrwM820.9(10105) INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE. 4r3." 4888-3 <br />By signing this CA Comprehensive Trip Log and Receipt, the signers) request that the information provided on this form will be considered confidential, proprietary and trade secret In accordance with Title, 14 CCR, Section <br />17041 et seq.. If a request is made for disclosure of this Information, the CIWMB will contact the signers) of this form at the address and telephone number provided on this form or recaipl. <br />Vch Cie' nformatt <br />Truck uecai number Hauler Address � <br />Business Name <br />�,.� �^•,_r, �, �� ! �- l� �jfr,�` �; •r.��; <br />, 1 <br />P D <br />Address <br />` � :I. City, State and Zip <br />License Plate P:.;IT1bel Sia I C " (1-yt 0C <br />.�. �> �.; •:L_J �_�. _� U ` � � � Common L <br />.___ C�irl•ier cr �. <br />1 cerliy under penalty of perjury under the laws or the Stale of Califomla that the Information pmvidad above Is true end C—acl. In addition. I am re lhaI alsification of this htgdnalion may result in suspension, moccation, or denial of renewal of In <br />Waste Tire Hauler Registration pursuant to Public Resources Cade section 42960 and may result in civil penalties up to $ 25,000 per dJavy. der vl a0on or administrative penal up to 55.000 per violation per day as described in Public Resources <br />Cad. section 4262 - / Ike' �/ (t . - <br />rr ! ( ,_ <br />i h C� (. S Y [� t a��4i r� <br />Driver's Name (print) Driver's 8!90-a Kre Date <br />3248883 -- C 1 :rii ME w- p De L11 LLJ L01 L01 (� HI Li <br />Hauler Tire Program ID / Site Suffix Facility Telephone Number <br />DATE ` <br />aw. E]Whole Tire Count Weight in Lbs. t <br />Q) � t 3 /� ( Volume Cubic Yds. ❑ Weight in Tons' <br />oHaulgr N me <br />a <br />Hauler Telepptpan rnber <br />';1_ <br />3248883 -- B <br />Hauler Tire Program ID / Site Suffix <br />I I -1:' 1 ',11:- 1. I .:I 9 <br />Hau @r Name <br />Hauler Telephone Number <br />�i 01 <br />Comprehensive Trip Log NumbA <br />3248883 -- A <br />Hauler Tire Program ID / Site Suffix <br />Hauler Namc- <br />Hauler Telephone Numbl.r <br />J <br />Address Same as Hauler rnrerars <br />I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE _ <br />LAWS OF THE STATE OF CALIFORNIA THAT THE r <br />......... F— oonv,ncn came re T.— Aun In..Pcr l 1 <br />ick Up L_._!. Deliver a l ) w L-) LJLbd4 —L <br />j—( Facility Telephone Number <br />ATE <br />� hole Tire Count Weight m Lbs. <br />1ioflJrne CubicYtfs.❑ Weigkitin TonsL�SL <br />j �1?6 <br />�I <br />Ae Sipme iiisaullFa �amr�ers <br />I CERTIFY THAT UNDER PbUULTY OF PERJURY OF THE <br />LAWS OF THE STATE OF CALIFORNIA THAT THE <br />-� Up. 7elive.: <br />Facility Telephon umber <br />_nPFPnnOOE <br />ho Tire tint, eight in <br />j <br />V lura CU c S. Weight in Togs �•{? (, <br />G, <br />Addrl -.s Same s Hauler rniffafs <br />I CERTIFY THAT UNDER PENALTY OF PE CF THE r <br />... .. _ L . � ewc nc T_ CTeic nF re, .—PNIe THAT TUF <br />