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M <br />N <br />Callfomla Integnew Waste Management Board <br />CA Comprehensive Trip Log and Receipts .'10002 P.o. ZI a125g, sac re mento, 8C 05012-01 5g <br />Elis AjM P L Ej 111213Com rehensive Trip Number <br />—5J INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE 3 4 4 0 2 5 9 <br />By signing this CA Canprehenahro TdP Log and Reaalpt, IM atgner(s) romroat Met Me ln! m Uon proHdW en W, lorm will M o Nlsred c-AftnUaL. p PYOry and'DNN, aen:reL In a000rdRros wMr no. is CCR. S-0- . <br />.. 1TOe1 at seq., N • rOQ-1 Is meds for rDstlasuro of Ufa Imom,atlon, tM CIN'MB will cement Ma signer(.) M tlds form et UN, eddrasa end Mlepi—number pro lded orr MY farm a remlpl I. <br />e cls ii ormetlon 'Hauler Address <br />Truck Decal Number <br />Business Name d Ca/�j"tjl IZ:S , <br />Address W 1:1...'564 <br />City, State and Zip ST o <br />License Plate Number State L. l,- 1 <br />©a a ® Common <br />Carrier. <br />s, e <br />I Dertily under peiWty of pPlury urge Uro lewd of U,a slate Ca1lMrda Mal Me information P Idea above Ie true end mreq, In addifion. I am swan gut f.WkeIon of ods o forma n rmdt <br />Wase Tbo HauIP Regi1 P111 purse be e Cade sedWn 1198f1 artl may rmult li, dW patulEes uD to f 15.000 roaY suspen9an, ro+ocallon, ar dsNal d mrwat d tlN <br />Code eectbn.19a2 11/VA!\•/T!—� ..... Oar daY: per violaUonoi+adrmistr_atlw Pe s uD o S5.0gg Pm Dar daY � Pud' R ,1 <br />0.8.19907030 �G Nj• <br />. • Driver's Name (print) Drivel's Signature Da <br />Comprehensive Trip .. Number Loadation Facility Tire Program ID Site Suffix <br />Y <br />34=402.59 .:�:_`+.... :: ,Pick UP",) elivery. <br />Hauler.Tire,Pro ramlD._/..Site-Suffix. P <br />g Facili Telephone Number <br />I ME - <br />O PIJE o HERH WHote Tire Count Welght In Lbs. �. <br />('' I Facility Business E C' % �t QIKef <br />•" a— �)/ I kVolume Cubic Yds. Weight In Tons Name/Address <br />E City, State and Zip <br />mHauler Name - ` <br />�- •Stam ortabel OK5 <br />Hauler. Telephone Number :Address Same as Haulet- <br />(N /A for 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF TNE' <br />�' • ,-,�� `t N/'- L • Whole Thea) LAwg OF THE SATE On CAUPORNmTM .Tun E <br />be' <br />¢ <br />3 4.14 0 25 9: --" 8.. <br />Pick Up Delivery <br />Hauler lire Program ID. / Site''Suffix% <br />r DATE <br />- <br />Facility Telephone Number <br />m <br />Sao- <br />r� <br />1t <br />a Whole Tire Count O Weight In Lbs. <br />Facility. Busi ss 1G CAMiN4;t f <br />Volue Cubic Yds.W <br />m; eight In Tons <br />Name/Addre s <br />City, State Zip 211 j� <br />c <br />o <br />v <br />Hauler Name - <br />ot ` <br />'20001a <br />a <br />i Stampor Label O I�•� <br />�h r yy <br />u lu W <br />Hauler Tele hone Number a • <br />• <br />Address Same as Hau <br />`p (N /A for, <br />�/ - —1 i . y - Whole TIRE) <br />111 <br />I IFY THAT UNDER PENALTY OF PERJURY. THE <br />.UW OF THE STATE OF CALIFORNIA THAT TNE. <br />MFORW N PROVR)ED ABOVE IS TRUE AND CORRECT. <br />Comprehensive Trip Log Number Load Information <br />Facility Tire Program ID Site Suffix <br />3440259 -- A Pick Up Delivery141 <br />Hauler Tire Program ID / Site Suffix <br />DATE <br />Facility Telephone Number <br />non a <br />m <br />w []Whole Tire Count � Welght In Lbs. <br />a <br />Facility Business <br />❑ Volume Cubic Yds. ❑Welght In Tons <br />Name/Address <br />o <br />Hauler Name <br />CODE0 as <br />City, State and Zip <br />StamP or Label OK <br />Hauler Telephone Number <br />Address Same as Hauler Initials <br />(N /A for <br />Whole Ti)res <br />I CERTIFY YHAT UNDER PENALTY OF PERJURY OF THE <br />LAWS OF THE STATE OF CALIFORNIA THAT THE <br />MFORYAYION PROVIDED ABOVE Is TRUE AND CORRECT. <br />