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T Oil i:ree www.QII s ` u ar �► <br /> cahitomfa magmted war.. ' <br /> CA Comprehensive I rip Log and Receipts 10002 P.o.Box f2ss.s••••mn• <br /> E'x!A M I P E 2 2 - 31Com rehensf� <br /> C1WN8103109 <br /> s"`" "bre` INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE •STAPLE OR DUPLICATE <br /> By signing this CA Comprehensive Trip Log and Receipt.the signers)request that the Information provided on this form will be considered confldsntlal,proprietary and tr•d-secret In aarnrda_ba w•h TXW a� <br /> 17041 at seq.,if a request is made for diaclosure of this information,the CIWM8 will contact the slgner(s)of this form at the address apd telephone number pro rld•d on this Icvm or receipt <br /> Hauler Address <br /> Truck Decal Numberr� <br /> Business Name <br /> © � D 0 } [1 Address <br /> City, State and Zip <br /> 9009LJE �LiiicensePlate Number State© 9 Carrie�n <br /> I certify under penalty of perjury under thn laws of the State of Caldorma that the information provided above is We and correct.In adddaam aware I aaware that falsification of this information may result in suspension,twooslim 41(1*rl/ <br /> •f <br /> Waste Tire Hauler Registration pursuant:o Public Re ounce Code section 42%0 and may result in civil penalties up to$25,000 per day,per mlabon or admimstrabve penalb"up to$5,000 per violation per day to tia•[r6ediA�VMb <br /> Code secbon 429§Y- <br /> 51 <br /> Drive s Name rrrint) Dri er's Signature <br /> Comprehensive • Log Number Load Information <br /> x <br /> 34979411 -- C Pick Up Delivery` a a a Deasier <br /> l <br /> DATE / / Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix <br /> Vl <br /> � w Whole Tire Count Weight in Lbs. <br /> m SEEM, F" Volume Cubic Yds.❑Weight In Tons t'nn/Address <br /> E ..:-y, State and Zip <br /> o Hauler Na 16 <br /> cwt o; Label OK <br /> U —« <br /> Address Same as Hauler <br /> Hauler I ell tnlie tr: :t r ■ " <br /> CERTIFY THAT ut4oER PENALTY OF PERJURY OF THE <br /> 7 wr•01•Tine) LAWS OF THE STATL'OF CALrORI•A IMT THE <br /> 3497940 -- B Pick UpDelivery <br /> Ile of <br /> LLJ <br /> Facility DTelephoneN Number <br /> Hauler Tire Program 1D / Site Suffix DATE <br /> 0 <br /> 2 <br /> e w Whole Tire Count Weight in Lbs. , <br /> 3wti�� lam, <br /> El Volume Cubic Yds. Weight in Tons r• + <br /> E <br /> Hauler Name �IV <br /> Haute+ f 2'e^nc ne ". ■ Ad�ess Same as Hauler <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PE)IJl1RY OF M <br /> whole TWIW LAWS OF THE STATE OF CAUFOrwtA THAT THE <br /> U i ! <br /> Comprf,hensive • 11111116791111,14 •. • • • • a <br /> -- <br /> 349794o -- A Pick Up ❑ Delivery <br /> Um DATE �I 1 / / ®© Facility Telephone Number J <br /> Hauler Tire PrograID / Site Suffix U <br /> c a. 2 Wh.le Tire Count �Weight in Lbs. <br /> / <br /> sales, 0 Volume Cubic Yds. Weight in Tons <br /> a Address Same as Hauler <br /> HaulerTelept.. :?e Ittr:notODD) pl!�� Owoo <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF TME <br /> (N/A for UWS OF THE STATE OF CALIFORNIA THAT THE <br /> ^^^r <br /> i 1 Whole Tlres) <br />