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Toll Free 1-866-8` 0600/www.ciwmb.ca.gov/Tires/ <br /> California integrated Waste Management Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 <br /> IIA: E X11'A+M;P i L E i 1 12 3� Com rehensive TO Number <br /> CWM92oipmos INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE 362 8 4 7 4 <br /> By signing thls CA Cemprehenslve Tdp Log and Receipt,the signer(s)request that the Information provided on this form will be considered confidential,proprietary and trade secret.In accordance with Title,t4 CCR,Section <br /> 17041 7 <br /> et seq.,II a request la made for disclosure of this Information,the CIWMB will contact the signor(,)of this form al the address and telephone number provided on[his loam or receipt. <br /> Decal Number Hauler Address <br /> © — a Business Name <br /> Address TUFF BOY SALES, INC. <br /> License Plate Number State City, State and Zip 3870 W. YOSEMITE AVE., <br /> LATIiROP, CA 9533Q• <br /> Cemmon <br /> Carrier <br /> I <br /> I certify under penalty of perjury under Ne laws of the State of California that the information provided above Is true and torted.In addMon,1 am aw§re Net felsM <br /> callon or this Information may tgWt In su,penabn,revocation,or denial of renewal ot tn. <br /> Waste Tire Hauler Reglseebon pursuant to Public Resources Code section 42960 and may result In dull penalties up to S 25.DDO par day.per violation or adminlsnattve penalties up to 55,000 per violation per day as descdbed In Public Resources <br /> Code section 4272 <br /> Driver's Name(print) Driver's Signature Date <br /> iComprehensive Trip Log Number Load InformationFacility Tire <br /> Program <br /> 3623474 -- Cgram ID Site Suffix Pick up Dell,very <br /> P QEHOEE-EE <br /> U <br /> Hauler Tire Pro / nn Facility Telephone Number <br /> DATE �� <br /> �a w Whole Tire Count []Weight in Lbs. a <br /> Facility Business <br /> ❑.Volume Cubic. Weight in Tons Name/Address <br /> E HauleLN, � City,State and Zlp <br /> �, O Stamp or Label OK <br /> Hauler Telephone Number ■ ) Address Same as Hauler Initials <br /> < IN/A for <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> +;ry LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> .'INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip •• Numberss Information <br /> 3 6 2 8 4 7 4 -- B ap <br /> ick up Delivery <br /> U <br /> der Tire Program ID / Site Suffix FacilityTelephone Number <br /> g DATE a� / BE, <br /> /,; P-Boa © 000 <br /> M a Whole Tire Count <br /> M Weight in Lbs. <br /> Oo © <br /> Facility Business <br /> m. F1 P.171 Q El.'Volume Cubic Yds.E]Weight i i Tons Name/Address <br /> o Hauler Name pp II City,State and Zip <br /> U Li !Od 5 s .6 ■. / :Stamm or Labei O%; <br /> Hauler Telephone Number �� / [_] Address Sartre as Hauler Initials <br /> ry'+ <br /> N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> / LAW9 OF THE STATE OF CALIFORNIA THATTHE <br /> a� L ✓ WhOIaTlFee) <br /> INFORMATION PROVIDED ABOVE IS TRUE AND"CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> .y <br /> 3628474 -- Q7� P­ 00000 � �-00 <br /> ick Up silvery j <br /> viaC` Hauler Tire Program ID / Site Suffix. Facility Telephone Number <br /> DATE'. <br /> ED H-® 50� 0 � � <br /> D ,.: <br /> D 2w ®Whole Tire Count ,aWeight in Lbs. <br /> QFarillty Et�sin <br /> o d 6 Volum_e,Cubic Yds.,E]Weight in Tons Name/Address <br /> Hauler Name "°``° h City,State and Zip <br /> i <br /> ) T ,Ff� StatTaip or°...abed s.fF,: <br /> i Hauler Telephone Number a Address Same as Hauler m;nals <br /> OI, J 1 I n I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> (N/A for <br /> Whole forTinLAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />