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.� - --=+� Com rehensive Trip Number <br />a <br />JIE X A � 4202650 <br />State arCLLYomla <br />C1 WezoalingsJ INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE <br />nd telephone number provided on this form or recoipL <br />By signing this CA Comprehensive Trip Log and Receipt, the signer(s) request that the information provided on Mis forth wall be considered confidential, proprietary and trade secret In accordance with Title, l4 CCR, Section <br />17041 et seq., If a request k made for disclosure of this inforTstalem <br />hCFWMB A1I contact the signer(s) of this <br />form at the ad P p <br />Vehicle Informationddress (' MU I <br />Truck Decal Number Name <br />a Py''i.t)/ <br />n [09 '� a ® City, and Zi '7 <br />License Plate Number C� C�iGn <br />P a ❑ ❑Carrier <br />above Is We and correct. in addition, I am aware at fall' cation of IN info tion may resuvltlolatioin �eer day as described in Public Resonsion revocation, or denial of urces <br />I certily under penaltyof perjury under the laws of the Stale of Catiromia that 29 0 and as provided nalties up to S 25,000 per day, per vidatia ar ad ishative penalties to S5, <br />Waste Tire Hauler Registration Pursuant to Public Resources Code seUion 42960 arM ma result in civil pe i <br />Code section 42962 A �.� A� I iTTI- O v <br />Driver's <br />w 4202650 -- C <br />a <br />il <br />4) Hauler Tire Program ID I Site Suffix <br />V N <br />m � <br />P o hauler Name <br />t `\i 0 K <br />J U ` ik <br />i rauler Telephone Number <br />I w-AXIM ii <br />,ick Up I I Delivery <br />DATE H © / E® / 0 <br />Whole Tire Count U Weight in Lbs. <br />Volume Cubic Yds. Weight in Tons <br />0 � <br />Q L <br />■ <br />(N IA for <br />of, <br />Tires) <br />�UUUU�U-uu <br />Facility Telephone Number <br />ON - EMM <br /><,tzy '.1J or Label Oi4 <br />iA;address Sarre as Hauler Iniiddss <br />ERTIFY THAT UNDER PENALTY OF PERJURY OF THE — <br />MWS OF THE STATE OF CALIFORNIA THAT THE <br />4202650 -- F3 PickupLl <br />Delivery <br />Q Facility Telephone Number <br />Hauler Tire Program ID / Site Suffix / <br />�! o: DATE / Ms f C� �✓I <br />fn t� ❑❑❑ <br />U1 �❑ ® c <br />a Whole Tire Count Weight in Lbs. <br />Volume Cubic Yds. ❑ Weight in Tons <br />0 Hauler Name <br />i iv iJ t� �'� � � �Ef't ��� <br />e„ ¢ ■ ❑ Address Same as ;-:auler lnitiis <br />8 If(�'I.UISf. elel3liofie Niif1713Hr (N /A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br />H r' Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br />„ O � � � <44 <br />t � %'1 INFORMATION PROVIDED ABOVE rs TRUE AND CORRECT. <br />-- gDelivery W®®4202650 A �PickUp <br />�j F ility Telephone Number <br />n <br />O <br />U <br />ac <br />Hauler Tire Program ID I Site Suffix DATE U Z <br />❑ ®® <br />❑❑ <br />Vol,,, <br />. <br />n [] Whole Tire Count Weight in Lbs. <br />loll El Volume Cubic Yds. ❑Weight in Tons <br />ns MHO <br />Hasler Telephone Nurnlaer. (N IA for <br />7, 0 g 4(97- <br />4 ft. 6 rC Whole Tires) <br />�- C A -f -t l vjJ 0 <br />it <br />❑ A€ dress Sane as Hauler InitiaLs <br />I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br />LAWS OF THE STATE OF CALIFORNIA THAT THE \ <br />