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CalHofnla Intograted Wasro Management Board <br /> : A CA_Comprehensive Trip-Log and-Receipts . ioov . P.O.Box 1258;SacrarrilCA95812-1269 • '. <br /> �, �" Comprehensive TriNumber <br /> C )<;A lir, ;'�. L;E F 2 ;�? - .�- <br /> =rZ� INSTRUCTIONS 6.N-BACK OF PART 2 '1316-NOT TAPE STAPLE"OR DUPLICATE 40602191 <br /> By slilinfna tlde CA CompreMmlve Trip I"end Realpt,dw elpner(s)regaaat the the btformaaon.provldsd on Ode form 1410 be core"ered 00111111111111131111111,Proprietary and- I necret In accordance wM TNM,14 CCR Section <br /> 17041 et peg.,its request b weft for dbelosum ofthis bdor neilon,the CWNM will com ata fie aftner e)of O&form et U,e addrw and IeNphone nrmib•r provided on ode form ar rtcelpt- - <br /> V. al Num ehlcle'I onnauonr Hauler Address <br /> truck Decal Number Business Name <br /> — ® ..P Address.. :P, <br /> City,.State and Zip <br /> License Plate NumberState >� <br /> Common <br /> Ed.0 .Garnier. .:. ' . <br /> I eertify undef'pe ty of perjury under the laws of Me State of California that the Information provided above is true and correct.In addition;I am aware that b on of fhb information may resub in-suspension,revocation•or denial of renewal of Ib <br /> -Waste Tire Hauler egislretbn Derwent to Public urcei'Code section 42960 and may result In civil penalties up to 5 25,000 per day.per "lation ora alive penalties $5.wove, <br /> ation per day.as descdbed.in Public Resources <br /> ALCode section 4296 .y r,1: / -) <br /> 'D ve s are print rn s Si fere ate ! <br /> WIT re 11 <br /> 4 0 6 0 2:19 C» Pick'Up-- . ' Delivery <br /> Hiiiilee Tire Program'lb- %Site Suffix Facility Telephone Number j <br /> H DATE �. � % Ek] <br /> l <br /> to w e Whole Tire Count El Weight In Lbs. I <br /> Fa 3 <br /> !' 1 J <br /> o V ( 11 Volume Cubic Yds.E]Weight In Tons' P96 aid' <br /> E Hauler,Name `10� �!(�: v <br /> a t. .. Address Same as Hauler: <br /> Haulec.Telephone Number <br /> _ —^y (N IA for I CE RM 711AT.WMM PENALTY OF PE PJM OF THE <br /> 77 Vnp�nom] L=AVIS TNT THE <br /> RIOVNt�ABOVE 0 TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix=: <br /> 4 0.6-0 21.9 �- .B .Pick-Up= Delivery . Elm' <br /> - <br /> - Facili - Tele hone Number <br /> Hauler Tire Program 1D / .Site;Suffiz tV . P ! <br /> • � _ - •. : . DATE•©©.� <br /> EF] <br /> ' .�H; <br /> _ .. ... -: <br /> w � ETWhole Tire.Count 1 Q Weight in Lbs:'. <br /> eaflaeo <br /> .. � .. <br /> m Volume Cubic Yds:•❑:Weight In Tons <br /> -Hauier•Name- t ' <br /> S . <br /> cc <br /> ■ :. Address Same as:Hauler. . <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> H7Uyle�jr elephotle:NumXb�e�l!JN,': (MIA�r i CMrTFr Twin UNDER PENALTY of PERJURY OFTHE i <br /> • �T�: '`5 �:."(/'r 'b-' .. <br /> Whole TIM) _LAMB OF.THE STATE OF CALffORtOA THAT Txfk_.., J. - <br /> brogmTION PROVIDED M TRUE AND t:ORRECr.. <br /> CL <br /> Z. 4 0 6 0 2:19 =-: A Pick Up El <br /> Delivery <br /> HaulerTire Prram ID, ./ Site/Suffx r.... <br /> Facility Telephone.Number <br /> ~ DATE <br /> ww a Whole Tire Count UWeight in Lbs. <br /> rFaciliPf,{��}`�:a��In_[e <br /> d l w 0 Volurlie Cubic Yds: Weight In Tons NaYv6e r4i lQ - <br /> oHauler Name_ <br /> j a Ad Same:as Hauler <br /> . . <br /> Hauler Telephone Number ■. <br /> CERMF TWIT IDIDFII Pei OF PERAW OF THE . <br /> � ....•' _ ��. (N/A for LAWS OF 141(5 STATE OF CALIFORNIA TMT ABOVE Ia TRUE AND : �• <br /> Whole AND <br />