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1 California Integrated Waste Management Board <br /> y CA Comprz-hen i��' -L�g and Receipts 1 P.O.Box 1259,Sacramento,CA 95812-1259 <br /> �p �t ,4 �,�;y S <br /> Comprehensive Tri Number <br /> � _- --� <br /> ciwn"fe'za3j,aos�INS RUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DI�PLI344. 394 <br /> CATE <br /> By signing th+^CA Comprehensive Trip Log and Recelpt,the signer(s)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 at soq.,If a request is made for disclosure of this Information,the CIWMB will contact the signer(s)of this form at the address and telephone number provided on this form or recelpt. <br /> ' <br /> Vehicle lnxorrnation ,�( ti <br /> Truck Decal Number esu , ` c���✓� A <br /> Adoaf- 1 t: C 0 U,!!T Y � ��i� iti i tLicense Plate NumberState � - � ; ,,,, 'T ) �} ? ;�S— <br /> l� Fi ALTH DEPARTMENT <br /> LJ Camon <br /> Carrier <br /> I certify under penalty of perjury under the laws of the State of California that the infor nation provided above is true and correct.In addition.I am aware that falsification of this information may result in suspension,revocation,ordenial of renewal of thf <br /> Waste Tire Hauler Registration pursuant 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 d�s described in Public Resources <br /> Codes-qg.�62t..`�` (, � L., ,�-- ar'1-�� �.... ✓ ��> '._,r�tl—�� <br /> -15-river's Name(print) Driver's Signature L Date <br /> • . . .. . .• <br /> 3443794 Pick Up Delivery o o a o a a o <br /> a0i Hauler Tire Site Suffix ID Program / Facility Telephone Number <br /> � g DATE a D / a� / � <br /> W Whole Tire Count Weight in Lbs. <br /> naa-aoaa - o <br /> El <br /> y Facility Business 7 <br /> d s ~ <br /> ElVolumeCubic Yds.11Weightin Tons Name/Address �' <br /> oHauler Name City,State and Zip <br /> CA <br /> V a Stamp or Label OK <br /> Hauler Telephone Number ■ D 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 /> �. <br /> 3443794 Pick Up Delivery <br /> Number <br /> n <br /> l <br /> Hauler Tire Program ID / Site Suffix Facility Telephone N <br /> .. DATE - ' - <br /> uta Whole Tire Count D Weight in Lbs. <br /> aao-o �00000 <br /> a Faoi(ityi �►eess <br /> `m ; ® ~ Volume Cubic Yds.a Weight in Tons NatneTtidtfrs r J <br /> 1 ' <br /> o Hauler Name City�; tiafanGI ''•a11�� <br /> V a DE <br /> Stamp or Lzbat Olt <br /> Hauler Telephone Number ■ n 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 /> k Up El Delivery r <br /> Hauler 71r3 Program ID I Si.e Suffix�; Facility Telephone Number <br /> DATE <br /> ra u Whole Tire Count Weight in Lbs. <br /> yg f ~ Volume Cubic Yds. Weight in"..ons i <br /> 1 <br /> Hauler Telephone Number 4 ■ FlAddress Same as Hauler Initials 1.1 <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 />