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Toll Free 1-866-896-0600 / www.ciwmb.ca.gg�viTirE...vi , L ,-, ii <br /> California Integrated Waste Management Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 <br /> Cc <br /> mprehensive Trip Number <br /> snre U <br /> A13 203(105)INSTRUCTiONS ON BACK OF PART 2 60 NOT TAPE, STAPLE OR QUPLICAT!E� 33979,91 <br /> By signing this CA Comprehensive Trip Log and R&*++e�6)6Asf�"tlQ I Nnra?rn-provided on this form 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 no Vt the signer(s)of this form at the address and telephone number provided on this form or receipt. <br /> Vehicle'rd-i=" <br /> Truck Decal Number E)EP A R filgWer Address 71 <br /> Business Name <br /> Ul <br /> A,�- \j <br /> Q <br /> Address u] 0 F] City, State and Zip <br /> License Plate Number State <br /> E.9 O "� ® ® � Com.mon <br /> Carrier <br /> I certify under penalty of perjury under the laws of the State of California that the information provided above is We and correct.In addition.I am aware that falsification of this information may result in suspension,revocation,or denial of renewal of the <br /> nt to Public Resources Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources <br /> Code sect! 71're",pursuant <br /> VA <br /> Driver's Name(print) Driver's Signature Date <br /> 3 a <br /> M <br /> og <br /> oFaci am.-IU Site SUffjX <br /> orma ion lijV.:T Prir 7, <br /> 3397901, Pick Up ❑ Delivery <br /> (DHauler Tire Program ID If Site Suffix as Facility Telephone Number <br /> DATE a D We/i [][] <br /> ght in Lbs. <br /> is C Soo-oaoaooa <br /> W Whole Tire Count 11 – <br /> (L I Facility Business <br /> Volume Cubic Yds.[]Weight in Tons Name/Address <br /> E City,State and Zip <br /> Hauler Name <br /> 2 Stamp or Label OK <br /> Hauler Telephone Number DE000MED r] Address same as Hauler Initials <br /> (N/A forI CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Colliprehensive Trip�Log,Number Load Information Facility Tire Program ID Site Suffix <br /> 3 397901 B Pick Up Delivery a a a-a <br /> 3 <br /> Hauler Tire Program ID I Site Suffix Facility Telephone Number <br /> DATE �a � �a�,� DD <br /> W Ono—DDD0 <br /> 11 Whole Tire Count Weight in Lbs. <br /> C <br /> Ha <br /> 0 <br /> um <br /> Ier <br /> r <br /> T <br /> CTS91 <br /> No <br /> ROW <br /> E] Volume Cubic Yds.11 Weight in Tons Name/Address P.O. Box I <br /> LE City,State an <br /> 0 Hauler Name 191co,CA 9530-D <br /> Stamp or Label�09)668-4855 <br /> Mauler Telephone Number ■ F] Address Same as Hauler Initials <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> "Ot <br /> aoo � � i <br /> ' -3 <br /> , <br /> 39791 -- <br /> L�- y Pick Up Delivery <br /> i �%3L30fl ' O a- �'J <br /> 41 Hauler Tire Pregram 0 Size Suffix <br /> Facility Telephone Number <br /> DATE , t .s <br /> / Ldo ii <br /> 0 <br /> ruill Whole Tire Count Weight in Lbs. <br /> IL <br /> IL <br /> Facility Business 0�1-k vac <br /> V <br /> I 1A I C, I Volume Cubic Yds. []Weight in Tons Name/Address <br /> E TLO� hAkKt,:�^—1 <br /> .o Haular Name Cit" S,-,n 7rd Zi I " 'AIN <br />