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Toll Free 1-866. '4600/www.ciwmb.ca.gov/Tires, Callfomla Integrated Waste Management Board CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 ` A0. MPL12 E 3 =f Comprehensive Tri Number EX JOS 20J�1�5)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE 3628 4 7 6 By signing this CA Comprehensive Trip Log and Receipt,the signer(s)request that the Information provided on this form will be considered confldantlal,proprietary and trade secret.In accordance with TIlle,14 CCR,Section 17041 at seq.,8 a request Is made for 113CIOaure of this Information,the CIWMB wlll contact the signer(a)of this form of the address and telephone number provided on this form or receipt. ,1c1<Decal Number Hauler Address Business Name j f 56,Add ❑ _ ❑ ❑© ❑ © City,Stateand Zip License Plate Number State ' o© FA Carrier EB11111110 eron I camy under penalty of Pehury undo,Ina laws of the slate of Calllomla Ihal the information provided above Is We and corl.In addition,I em aware mat falsification or this Information may result In suspension,revocation,or denim of renewal of Ibt Waste Tire Hauler Registration pursuant to Public Resources Code section 62960 and may result In civil Penalties up to$25,000 per day,per violation or administrative penalties up to S5.D00 per violation per day as described In Public Resources Code section 42962 Driver's Name(print) Driver's Signature Date Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix •,n 3628476 -- C ick Up ❑ Delivery _ Hauler Tire Program ID / Site Suffix FacilityTelephone Number ¢ g DATE y / P M © 0❑-®0© �� ❑ ❑ ❑ wa Whole Tire Count Weight in Lbs. ,Facility Business Volume Cubic Yds,O Weight in Tons Name/Address E Hauler Name City,State and Zip fn }� U L-1 1, s, Stamp or Label OK Hauler Telephone Number a ■ Address Same as Hauler Initials I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE (N/A for LAWS OF THE STATE OF CALIFORNIA THAT THE J.�( J J •. ::2[fW11 r Whole'Tlres):. INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. tiw Comprehensive Trip Log Number Load InformationProgram 3628476 -- B I /- alp Delivery n iauler Tire Program ID / Site SuffixDATE Facility Telephone Number � ®❑ / ❑c� / aW Whole Tire Count ❑Weight in Lbs. ❑ C , ®© �n © ©❑ Facility Business a! l C P-1 714. b 1 ( ❑lNol`me Cubic Yds.❑Weight in Tons Name/Address Ty' o' Hauler Name ` City,State and Zip N -71 n3 Stamp or Label OK Hauler Telephone Number ■ Address Same as Hauler Initials G J(/' I LL (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVEIS'TRUIE�AND CORRECT. Comprehensive Trip Log Number Load Information a 3628476 -- A ,t Ick Up '`` ❑ Delivery' ��' ❑ ❑ Hauler Tire Program ID / Site Suffix �J Facility Telephone Number ¢ g DATE / �I S I / C, � _ .� I N LJ ® � ❑ ❑❑��❑ ❑❑ a 11 Whole Tire Count []Weight u1 Lbs. } Facility Business ~ ❑Volume Cubic Yds.[]Weight in Tons Name/Address E Hauler Name City,State and Zip U. FF �v`" Sy4/� ~ ❑ Stam or Label OK❑ P ;NA Hauler Telephone Number a ��■ - Address Same as Hauler in;r;s 1 CERTIFY THAT UNDER PENALTY OFPERJURY OF THE (N/A for, ..13 *�� ` �v✓ G' r• / "�� + 1 y�m� W hOla Tlheya LAWS OF THE STATE OF CALIFORNIA THAT THE �-^', .INFORMATION PROVIDED ABOVE IS TRUE ANO CORRECT. `---tom /�` a I W [/✓wfY`i_ —7— � �C�%7^�T/`"�/� /�l � 'O/�..•