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W�!VMlrs My"" .A >`SE <br /> CA ComprehensivP Rip Log and Receipts 1 2 'PO. 2 ' unjo;�,� <br /> °.e. E;X{Nil M i P; Ir i E1; 11121131 _ COMPM enslvs ,. <br /> c we nil INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE <br /> F,,;k M <br /> By signing d"CA Comprehensive TN]Log and Receipt,the signer(s)request that the Information provltled on this form will be considered canfldantW.proprWwy . <br /> 17041 et seq.,If a request Is madm <br /> e tor disclosure of this Information,the CIWMB will contact the signer(s)of this form at the address sad telephone number provlded onOftMyttarm��~���W T - <br /> or <br /> Y <br /> Truck Decal Number Hauler Address ��� ..1�•-�„ r <br /> r1 Business Name <br /> Address . <br /> License Plate Number City, State and Zip y� �' T-zz C,:--, r• <br /> State <br /> EDP <br /> nMECoi nmon" E E <br /> Carrier <br /> I certify under penalty of perjury under the laws of the State of California that the information provided above is true and correct.In addition,I am aware that fabf cation of this Information may re"H atrspension,rewonlion, <br /> Waste Tire Hauler Registration pursuant to Public Resources_Q{yde section 42960 and may result in civil penalties up to S 25,000 per day,per viulatigp• ,roinistrative penalties up to 55,000 per vloWlon <br /> day as <br /> Code section 42962 / r <br /> Dr veri 's Name(print) DrIverYS49—iAture <br /> 7Tire <br /> . ..3 -- C Pick Up DeliverycFacili Tele hone Number Ip.:/ Site Suffix DATEtY p* sL 6 w Whole Tire Count Weight in Lbs.a,. F—aciiity Business <br /> Volume Cubic Yds.❑Weight In Tons Ir ..!Wrlress <br /> o Hauler Name•--: <br /> ti-, -State and Zip <br /> a <br /> V -!amp or Label OK <br /> n a E] Address Same as Hauler <br /> Hauler Teie hone Pv,,mu�:r ■ <br /> tN M for I CERTIFY THAT UNDER PENALTY OF PEIRJUMY OF THE <br /> IOM _ LAWS OF THE STATE OF CAUFOINA.THAT;R4l. <br /> 3497992 -- B Pick Up Delivery <br /> cD <br /> m <br /> Hauler Tire Program ID / Site Suffixo�DATE Facility Telephone Number oro oa _ <br /> c w ® © © x' .'1 <br /> eW �Whole Tire Count �Weight in Lbs. <br /> 71 <br /> E �} f =� � Volume Cubic Yds._aWeight In Tons x,a <br /> I - <br /> o Hauler Narne <br /> HaulsQ ' as HaulerAddr� <br /> yy (IN iK I CERnFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORNM THAT THE ,f - •q. <br /> 3497992 -- A Pick Up ❑ Delivery <br /> Facili Tele hone Number <br /> Hauler Tire Program ID / Site Suffix DATE p <br /> w�Whole Tire Count Weight In Lbs. <br /> r a <br /> Volume Cubic Yds. D Welght In Tons <br /> E <br /> Hauler <br /> Q L_� <br /> !-lauiel e;trrone htd f tx,. v ■ i ❑ Address Same as Hauler <br /> r 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THI! <br /> Whole <br /> Tires) - <br /> •4^ // ',.,`/i-'�=� _ (N LAWS OF THE STATE OF CALIFORNIA THATTHE_ <br />