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Celitomis IntBgreted Waste Management Board CA Comprehensive Trip Log and Receipts 10002 P.O. BOX 1259. Sa—Twento, CA 95812-1259 E x a M P i E1 111213Com rehensive Trip Number , mm(,,5)INSTRUCTIONS`ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE 34402 3 7, BY NenlnB Nls CA CompnMnalw TAP Loa'•rd Roplpt, Dna slanerl•) re9uad WI tlIs Infomutlon prvdeee on UN town MII a consleerea wnDdentlal. propAalery ab NY •ecreL In seeardmlre WN Pea, 10 CCfl, 9acoen 1741 et sp., a • ro9uesi la nraM IaI alubwn a Ihls IrAametlen, tl,a DIWMB MII Wlrtacl Ne elq.rr(al a W e form N ere aaan•s. and EalapNorra nlmMr prowaM on We loon er nrcalpl ' elf c e Inform " bn Truck Decal Number Hauler Address F C -P -A1 Ys Business Name . �.®—HN H® Address License Plate Number state City, State and Zip of S2'� 0 0 o a a o ®_ El o Carrier n I certify order penety of perjury order me lewe of Ne stale a Ceuromla foal Dr L'�I Ie provWed aeo.'e Is Wa ane anxt In aeaitlnn, I em avrare Net faLylA ebon a Nis inf-pawn m.y newt m susp•rWo., --don. or eeMel of renewal a Me wash Tine Meubr Re9HVatlon purvuenl d Puak Goae eectlm x2960 ata muy nwll In owl penaltles uP m S 25,000 par eay, per.vfolewnor.a n. intoe Penalties up to f$:000 Per woleeo as `'� 7 q� r as eeseneea In Pea a fleeow es � A^�` ee�� F U . ��j -(D Driver's.Name (print) �� DriJer's Signaiu�e f' Date IIIIIII • u • E • a . Lon u . .. _ .r ■ 3440237 __ A Pick Up ❑ Delivery 0000000 -DE Hauler Tire Program ID ! Site Suffix Facility Telephone Number _ DATE A F m w ❑Whole Tire Count [-] Weight in Lbs. Q. Facility Business m ❑ Volume Cubic Yds. []Weight in Tons Name/Address o Hauler Name City, State and Zip U 1:1 p Stam or Label OK Hauler Telephone Number ■ Address Same as Hauler initials (N /A for I CERTIFY THAT UNDER PENALTY OF PERUURY OF THE Whole Tires) -WS OF THE STATE OF CALIFORIM MAY THE INFORMATION PROVIDED ABOVE Is TRUE AND CORRECT. 340237. .��. �...... . ' Pick Up �%Deliyery Hauler.Tire.Program ID / Site Suffix DATE _ ©� / / r �� Facility Telephone Number . I��'►C�,1jy C13 :2 E w 'Whole Tire Count Weight in Lbs: a Volume CubicYs.❑WelghInTos [Facility Business tri- CA -10)17.10 - jq j- � f g U Hauler Name U,�C�11rJ� •-{'( dit<S � City, State and Zip�.,^ tV Gkto Stamp or Label OK. Telephone Number ■ Address Same as.Hauler Initial. J �H7auuller `r l `y ^2 tel/ (N /A for V — 1�✓ l ,Nh01B nlHe) 1 CERTIFY THAT UNDER PENALTY of PERJURY of THE ///�� LAM'9 OF THE STATE OF CAl1FORNIA THAT THE I A INFORMATION PROVIDED A w IS UE AND CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 34:40237 as' B Pick Up Delivery u � Hauler Tire Program ID / Site SuffixFacility DATE �� Telephone Number 2 -u Whole The Count .❑ Weight in. Lbs. f V S11 '50 0. Volume Cubic Yds., Weight In Tons Facility Busi essLL --tl�l(:j Name/Address m E V Hauler Name t L �+'1( tom... '� l i'ZES : :. �' "f a��aC �. City, St`te,'and•Zip �T qq Stamp or K. a Hauler Telephone Number ■ I_I l—i ... .. _ (N /A f0l.. Who1D nnse) -. Q Address Same as Hauler Initials 1 CERTIFY THAT UNDER PENALTY OF PERUURV OF THE LAWS OF THE STATE OF CAl1FORNIA THAT THE 77, 3440237 __ A Pick Up ❑ Delivery 0000000 -DE Hauler Tire Program ID ! Site Suffix Facility Telephone Number _ DATE A F m w ❑Whole Tire Count [-] Weight in Lbs. Q. Facility Business m ❑ Volume Cubic Yds. []Weight in Tons Name/Address o Hauler Name City, State and Zip U 1:1 p Stam or Label OK Hauler Telephone Number ■ Address Same as Hauler initials (N /A for I CERTIFY THAT UNDER PENALTY OF PERUURY OF THE Whole Tires) -WS OF THE STATE OF CALIFORIM MAY THE INFORMATION PROVIDED ABOVE Is TRUE AND CORRECT.