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CA Comprehensive rip Log and Receipts 10002 Bix'1M bdW1• <br /> I <br /> P L <br /> comprehensive. <br /> MIE 1 2 - _ _ <br /> CMW20alfw5)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE <br /> By signing thls CA Comprehensive Tr p Log and Receipt,the slgneo( )request that the Information provided on this form will be considered—ffdential,proprlMary and trade secret.M a we wYST q <br /> 17041 at seq.,If a request is made for disclosure of this Informatlon,the CIWMB will contact the slgnar(s)of this form at the address said IsiWiom number provided on tide form or receipt <br /> Truck Decal Number Hauler Address ? � <br /> F Business Name <br /> Addresis <br /> — ❑ �� ❑ ❑ ❑ <br /> City, Sate and Zip <br /> License Plate Number State �je <br /> Common <br /> UE, @ H E ID E U 1191 is Ca(iier <br /> 1 certify under penalty of perjury under tho laws of the State of California that the information provided above is true and correct.In addilion,1 am aware that falslficabon of this information may result In suspension,revocalson,or4afliaf of } <br /> Waste Tire Hauler Registration pursuant:o Public Resources Code section 42960 and may reauflin'civil penalties up to$25,000 per day.per violation or administrative penalties up to 55,000 per violation per y as desert*dG►rMo <br /> Code section 42962 <br /> Driver's Name (print) Drives re <br /> Comprehensive ipL <br /> Number Load Information Fac1itv Tire Proare.— iSt <br /> 3497941- lllI. `' Pick Up ❑ Delivery ❑ <br /> Hauler Tire Prorgsarrl ID / Site Suffix Facility Telephone Number <br /> � DATE ❑❑ / ❑❑ / ❑❑ 0`1 •'- • <br /> N w Whole The Count Weight In Lbs. <br /> ❑ ❑ ❑-❑ ❑ ❑ ❑ <br /> � � a F ISi?ies� �• <br /> y I � ❑ Volume Cubic Yds.❑Weight In Tons `4dr' r sS <br /> n Zip <br /> O Hauler Namecc-1 <br /> C-.f <br /> ~ t<1ral;I of r_£ahel OK <br /> Hauler l elephone Numt-Je;. EEEOEnE <br /> ❑ Address Same as Hauler <br /> (N lA bre'-...:: I CERTIFY THAT UNDER PENALTY of PEP may of T•tE <br /> LAWS of THE STATE OF CALIPOII•E14 <br /> AN I USIA <br /> 7Tire <br /> 1 __ <br /> B Pick Up E].-Delivery ❑ © a �' <br /> DATE Facility Telephone Number <br /> m ID / Site Suffix pC ❑ <br /> W hole Tire Count �Weight in Lbs. <br /> y !� t ; j I ~ ❑ Volume Cubic Yds.❑Weight in Tons <br /> o Ftauief Narnr. <br /> Lz <br /> Lk ,J - 4 a <br /> Hauler Tele nose N�—,M..fer ■ ❑ ddress Sarre as Hauler ;;�; <br /> p �+ (N/A for I CERTIFY THAT CINDER PENALTY OF PERJURY OF THE <br /> wr <br /> !_ pft�� LAWS OF THE STATE OF CALWORNA THAT THE <br /> INOMMUMMN PROVO=MOVE 0 TRIM <br /> a <br /> 349794-L -- A Pick Up Delivery © ® E <br /> a' Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> M: DATE <br /> w <br /> w <br /> m <br /> ole Tire Count Weight In Lbs. <br /> f <br /> a , <br /> Volume Cubic Yds. Weight in Tons '• <br /> o Hauler Name <br /> to r. <br /> 16, <br /> �^ ► ,, <br /> a r_. nle aVHd&f"er <br /> Hauler >ie�l ;,�, � ;, .: ■ <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF TIC <br /> ,r.._ IN/A for .._...__.. .---...._...__._ - .,. <br />