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Toll Fre 6-896-,0600 / www.ciwmb. ov/Tires/ California Integrated Waste Management Board CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 r r - �, Com rehensive Tri Number area„raml. ciwmraruesoslforos)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE 3393371 By aigning this CA Comprehensive Trip Log and Receipt,the slgner(s)request that the Information provided on this form will be considered confidential,proprietary and trade secret. In accordance with Title,14 CCR,Section 17041 of seq.,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 receipt. veh ct®�Informat o'rf Iia t '` - Truck.Decal Number Hauler Address �� '� co Business Narne 1170 io © — Foi o Pa Address Za Lot, Qe:a jn�, ✓iC�.cJ C T City, State and Zip (,Ci 5 f� -/ �'� $ License Plate Number State MoCommsg DRU 0 �._.._ Carriernn -- OPY — I certify under penally of penury under the laws of the Slate of California that the information provided above is true and correct.In addition,I am aware that falsification of this in rmabon may result in suspension,mvocalion,or denial of renewal of the 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 day as described in Public Resources Code section t2962 Driver's Name(print) river's Signature Date Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 3393371 -- C Pick Up ❑ Delivery ❑ ❑ ❑ ❑ ❑ ❑ ❑-� a Comprel Hauler Tire Program ID / Site Suffix DATE ❑ / �� / ❑❑ Facility Telephone Number N ❑ ❑ ❑®❑ ❑ ❑ ❑ ❑ ❑ ❑ e wa 1:1 Whole Tire Count Weight in Lbs. Facility Business d tttt— E] Volume Cubic Yds. Weight In Tons NarTieiAddress E Hauler Name C"', S'atsa i nd Zip N 3 t=erm,or t_ahei OK' Hauler Telephone Number U a ■ E] Address Same as Hauler Initials -� (N/A}Or I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Com I prehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix a 3339, 3371 -- B Pick Up ❑ Delivery © © -® Facility Telephone Number Hauler Tire Program ID ! Site Suffix DATE l� ehole Tire Count Weight in Lbs. ROW Facility Su Ines 2 �-Q d p S F- Volume Cubic Yds.❑Weight in Tons' N:1��j�A`�# Ns�s g� o HaulerName s' N � � U. Q Hauler 'eiephone Number ODOOD-00 Address earns as Hauler In fs (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE C Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE "le "-'�J / a INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. �- 3393371 -- A Pick Up El Delivery ❑® ❑❑ ❑® Facility Telephone Number Hauler Tire Program ID If Site Suffix DATE e LU hole Tire Count Weight In Lbs. M et .�- d I `17-10 ,5 Volume Cubic Yds. Weight in Tons nr1 oHainer Name _ 7 f .r U Q DODHOMOD HaulerT Ie phone Number , _.f Address,7arne a£ fla[11e!' Initials