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yes_ ecu; <br /> ?-nil �'r•�c� �� F��-,�<�tx-f1�fl� J w�r�rw.lrswcxr� +RI�IAerS/� �nss�o-�r <br /> C•lifoo Inteolrat•d watt• <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,aKa <br /> rnento0.�A' nti1 <br /> E XI A Mi I' t_ E 1 , 2 3 Com rehensive TrI <br /> srracrr+r <br /> cMWA03(10MA INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE �- <br /> By signing this CA Comprehensive Trip L.Gg and Receipt,the signer(s)request that the Information provided on this form will be considered confidential,proprietary and trade Ntrrt.In accordance wllh TIII•,T4 <br /> 17041 at seq.,If■request Is made for disclosure of this Information,the CIWMB will contact the signers)of this form at the address and telephone number provided on this form or radNpL <br /> Truck Decal Number Hauler Address <br /> Business Name <br /> Address <br /> a U © FLJ 0 E E City, State and Zip r <br /> License Plate Number /l State fes' <br /> / r Li Co m emon <br /> I c qfy 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 felslM1cation of this information may rasun in suspwuion,revocation,or dalW or <br /> Waste Tire Haule rReglsvation pursuant to Public Resources Bode section 42960 and may result in civil penalties up to$25.000 per day,per violates\admmisUative penal up to$5,000 per—latlai Per day m d•sabad in P*Ac <br /> Code section 4?962 <br /> Driv 's Name print Driver's—Slorliattirl <br /> • . - • . .. . <br /> x <br /> 34979-39 C Pick Up Delivery a o 0 o a a <br /> 0 CD A <br /> Hauler Tire Program ID / Site Suffix DATE Facility Telephone Number <br /> too 000a l <br /> w Whole The Count Weight in Lbs. . <br /> Volume Cubic Yds.❑Weight In Tons t <br /> E rty, sf).tt: and Zip <br /> o Hauler Name <br /> V off, or 1_al�ei OK <br /> a Address Same as Hauler <br /> Hauler?ele�thone Nun;ber ■ <br /> I CERTIFY THAT UNDER PENALTY Of P•A.q/IY OF THEIMOM r LAWS OF THE STATE OF(.AUFOR04A TMO <br /> Comprehensive Tr� <br /> :Ompr <br /> .. 34 9 7 9 3 9 __ B Pick Up Delivery 171 <br /> a <br /> Hauler Tire Program ID / Site Suffix DATE E <br /> / / Facility Telephone Number -_RD <br /> s U11 11MEND <br /> C wWhole Tire Count Weight In Lbs.Ila <br /> (� <br /> a I fh-11'� Je-Q <br /> t <br /> O I t / 'I ~ El Volume Cubic Yds.E]Wefght In Tons _ <br /> E Hauler Namr rof <br /> - <br /> �' E <br /> H <br /> H ler Telephone ;Jtut xir ■D D <br /> Address Same as Hauler <br /> /A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> ' W J. ' IN LAWS of THE STATe UJFa <br /> OF CwA THAT THE <br /> (!l{� <br /> a <br /> 3497939 -- A 1 -Pick Up ❑ Delivery ® � � r <br /> y Hauler Tire Program ID / Site Suffix <br /> Facility Telephone Number <br /> El <br /> DATE / / a ,� <br /> e a -Whole Tire Count Weight In Lbs. 4." <br /> Volume Cubic Yds. Weight in Tons ^+ r) �✓ <br /> E <br /> i inuIer IName <br /> Address Same as Hauler <br /> i'{�,_i Ii,,% -I.':') - ■ I CERTIFY THAT UNDER PENALTY OF PERJURY Of THE` <br /> iT� (N/A for I AW^r)F THE STATE OF CALIFORNIA THAT THE 4777 <br />