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CalMontla Integrated Waste Martagelttwnt Board <br /> CA Comprehensive Trip Log-and Receipts'. 10002 P.O.Boa 1259,sacranwrito:CA26812_1259 . <br /> FE X-s? teff• L;!w !. ;3' �—�� Com rehensive TriNumber <br /> � � . - .� 40880 66 � <br /> o ,wnoayINSTRUCTIONS ON BACK OF PART 2. .DO NOT•TAPE-STAPLE.OR DU LICATE <br /> ft•19ri tp Dd•CA WnpnMnaM Trip Lop and R-40.ttt••Iprwpt regrwat that the hdamrra0on prwld•d w atb form won be considered=dkimilwpophAwy and 4W••caL In acrord n wMl TM*14 CCR a0cdw <br /> 17061 K sea.,M•re I Is made far dbelosure otMin bdmma0oN do CIYgB win comm DM alplarls)ofMY form d Ma addrow and Ialepnone nornbar peovided wn MY fern or feoelpL-- . <br /> Vehicle InfomuttioniHauler Address " <br /> Truck Decal Number Business Name <br /> Address DANIELS-TIRE SERVICE <br /> H"— 00 2 ® 0 City, State and Zip 11850 E. Slauson Ave.- <br /> License Plate Number - State <br /> El <br /> Santa Fe Springs;CA 90670 <br /> j ® � D ® ❑ � � � �_ uCarrieon <br /> 1 certfy under penalty of pertury under the laws of the State of Caldomla that the Information provided above 1s nue and cared.In addition•1 am aware•thaf taf WcAdon or U•s Intomwaon ma esdal anon <br /> -Waste Tire Hauler Registration pursuant to Public Resor Code section 42960 and nay result in civil penal me y r onpe r UaX ae destbn.er denial ol-rercwW of <br /> s Cade seCron 42982 Q r YPe up to <br /> 25.000 per day per violation a.admimrstntive pereNes up to 55.000 per violation per dates described in Pubic R <br /> 1460711 -, 6 <br /> Drivef'.s Name print Driver's Signature <br /> t=' <br /> i .. . . . Program <br /> rauler <br /> 8.0 6 6' C Pick UP. a Delivery0 <br /> e Program:ID.:! .Site;Suffix' : Facility Telephone.Number <br /> - _ . : DATE <br /> : Wel h o 00,0000000. <br /> Lu Whole•Tlre Count g 1 Lbs <br /> � ,• �ciii8�f�rlstrte,s <br /> Volume Cubic Yds. J.Weight in Tons• �3atirZviAddre s' <br /> :$ Hauler Name pity;Slits�nd;Zip <br /> v &wnp or Labei'OK <br /> Address Same as Hauler <br /> Hauler Telephone Number. >- • E' ] <br /> . . 1 <br /> (N/A for I CERIF I Twtr Itlmet PEMUTT OF rMJM Dp THE <br /> Whole Trp) LAWS OF THE STATE OF CAUIWMA THAT TRE. . <br /> m a ue AND <br /> Comprehensive • Log Number Load Information _ Program ID Site Suffi <br /> 4 0 8.8 0 6 6 -- 'B Pick Up D Delivery <br /> Hauler Tire Program ID`''/. site Suffix ' Facility.Telephone Number <br /> iD <br /> _ Baso=Sao ® o � <br /> c i® Whole Tire Counti- Weigh in Lbs: <br /> facility 6usin"S <br /> 61 401100. lal I r.[] Volume Cubic Yds.❑WeIghtIn,Tons NamelAddress <br /> ' LS:TIR <br /> E Ha ler Name - l _ . �jy," �4I�IIE E $ERNICE <br /> U ,. � .,. ,-- _ . , .�`�1,1850 E:"Slauson _._ <br /> ��/SLS I• ( 3 <br /> MS- .AtaF :sr' 9Hauler Telepho m , ress arft�k%.Q. . 0,&Z <br /> 6 : '(N IA.for I carr Fr•T7iAr LANDER reiALr os PEA.amr of THE <br /> Cj L / y� •I Whole TIM*) s OF TW STATE of cAL�oinw TN.T TME i <br /> tlolfmm AttOV!Ia TRUE Alm a:oallccr. 1 <br /> Comprehensive . Log Number <br /> Program9 Site Suffix <br /> omprel <br /> -� <br /> =P�. U Delivery.iz L 40880.66 : . p. <br /> .Hauler Tire Program ID 7. Site Suffix Facility..Telephone'Number,-.: lj <br /> m DATE © � 119 FIR : 7 <br /> .0 W �Whole Tire Count a Weight In Lbs. . <br /> r d f= ;► a tr., p CTS C <br /> �' Volume Cubic Yds. Weight In Tons i <br /> a ❑ <br /> o Hauler Name <br /> Hauler Telephaa Nu ' r a Address Same as*Haul� J " <br /> (N/A for I CST THAT MOM PEMUTr OF PEHAMY G THE <br /> Whole for LAWS op TM STATE OF CAtgawuA THAT THllrE <br /> P ROMED ABOVE 19 tMM AND CORRECT. / . <br />