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Toll Free 1-866-1 0600/www.ciwmb.ca.gov/Tires/ •I California Integrated Waste Management Board CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 E i A* P T r Z 2 _ Comprehensive Tri Number CIA18x3(ins)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE 3463039 By signing this CA Comprehensive Trip 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,14 CCR,Section at asq.,If a request le made hx disclosure of this Information,the CIWMB will contact the aIgner(s)of this form at the address and telephone number provided on this form or receipt. .,;k Decal Number Hauler Address Business Name Address- P License Plate Number State City, State and Zip aaoo oo � up Common Carrier I cehry under penally of perjury under the laws of the Slate of California that the Information provided above la We and correct In addition,I em awero that falsification of this Inlom,atlon may result In suspension,revocallon,or denlel of renewal of IN Waste Tire Hauler Regisbalion pursuant to Public Resources Code section 42960 and may result In civil penalties up to$25,000 per day.per vlalallon or administrative penalties up to 55.000 r violation per day as described In Public Resources Code section 42867, river's Name(print) ver's Signature Date Comprehensive a Log Number Load Informationas ra Site Suffix 3463039 CLAPick Up 11 Delivery IONEHOOE-00 0 Hauler Tire Program ID / Site Suffix Facility Telephone Number DATE ED / < 2E W .Whole Tire Count Weight in Lbs. Q. Faclllty Business ?'ti,jz-f{ gar/ `y ) ( o- 0 Volume Cubic Yds.❑Weight In Tons Name/Address 3 F a y ase„�,7j F9 v E Hauler Name Clfiy;State and Zlp�ai NQG 9'3 3jcr 9 ��S Q [ I Stamp or Label OK Hauler Telephone Number ■ `�' ® Address Same as Hauler morale / (N To I CErmFY THAT UNDER PENALTY OF PERJURY OF THE WholeT r LAWS OF THE STATE OF CALIFORNIA THAT THE feS� INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. �/✓ Comprehensive • Log Number Load Informationas 1 Site Suffix a 3463039 -- B Pick Up Delivery auler Tire Program ID / Site Suffix Facility Telephone Number DATE, W w Whole Tire Count Weight in Lbs. 2 �7 (LFacility Business � al- 40)e s.q l4y y b ' O' Volume Cubic Yds'.'[]Weight in Tons Name/Address :3 S17a w ya,st= ,r,K J�` E Hauler Name City,State and Zipy/Le� N n �j 7—,t 7_,�7 6e,y -5,q les a �� Stamp or Label OK Hauler Telephone Number ■ ® Address Same as Hauler Inifials r� (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE 'T O — 1! •'L/l� I Wh010 TI—) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMAT10N PROVIDE.ABOVE'S TRUE'AND CORRECT. 1, 1. Comprehensive a' Log Number Load Information Program y Site Suffix p 3463039 -- A Pick Up ❑ Delivery Hauler Tire Program ID / Site Suffix Facility Telephone Number DATE-to E2;/ OE / I] - F-J-1 Count Weight in Lbs. EHH BEHM a c� } FacilityBUsiness 10 ( ~ Volume Cubic Yds.[—]Weight in Tons Name/Address o Hauler Name City,State and Zip U Stamp or Label CCK Hauler Telephone Number a�a ■ I [:] Address same as Hauler Initials �' I I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE IN/A tof LAWS OF THE STATE OF CALIFORNIA THAT THE 131 V W hole Tires) INFORMAnON"'P"ROOVVIDED ABOVE IS TRUE AND CORRECT.