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California Integrated Waste Management Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Bea 1259,Sacramento,CA 95812-1259 <br /> (~ X ANt P L E , i ; 2 3 -r"t Comprehensive Tri Number <br /> =NNar�'M>eAl12 7 9 3 1 <br /> cm,203(105IINSTRUCTI0N$ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE <br /> 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 <br /> lTD41 et seq.,if a request Is made for disclosure of this Information,the CIWMB will contact the signer(s)of this form at the address and telephone number provided an this form or receipt <br /> V.ehlCle'Inf0rtY7aU0n ""`ana <br /> Truck Decal Number Hauler Address' F �ralt►1av1 �,1 I <br /> / Business Name .. r <br /> _ R EEO <br /> Address <br /> City, State and Zip <br /> License Plate Number State <br /> L J Carrie on <br /> I certify under penalty of Perjury under the laws of the State of California that the information provided above Is true and correct.In addition,I am aware Nat falsification of this Information may result in suspension,.revocatlon,or denial of renewal of N <br /> Waste Tire Hauler Registration pursuant to Public Resources Code section 42060 and may result In civil penalties up to E 25,000 perday,per violation or adminlstrative penalties up to$5.000 per violation per day as described in Public Resources <br /> Code sectio�42962 <br /> jjj.L�,O % 1N ya v;,J� $e f. G 91 1:01 t VtAouaI i t <br /> Drive's Name print Driver's Signature J Date <br /> Comprehensive Trip .. Number Load Information Facility Tire Program <br /> m <br /> 4.1-27931. =- C Pick Up ❑ Delivery <br /> m Hauler Tire Program ID I Site Suffix Facility Telephone Number <br /> DATE a� / / a� <br /> _ ooa®oa0000a <br /> tc "Lu Whole Tire Count Weight In Lbs.. <br /> tL Facility Business. <br /> m I I Volume Cubic Yds.[:] Weight in Tons NamelAddress <br /> ErHauler <br /> auler Name City,State and Zip <br /> U <br /> Stamp or Labe{OK <br /> a Q Address Same as Hauler initials <br /> Telephone Number <br /> (N IA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE ' <br /> Whole Tires) LAWS OF TME STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE 15 TRUE AND CORRECT. <br /> Comprehensive • •• Number •. • Information 1 <br /> Site Suffix <br /> m. <br /> . 4127931 -- B Pick Up EDeliveryiNoflOMMHCL — <br /> Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix DATE / ® / E <br /> 03 Ell <br /> ora QI Whole Tire Count []Weight In Lbs. <br /> �Fj <br /> �1 i �i�i� E] Volume Cubic Yds. Weight in Toris. 0ir9$SpE to �,Zi�,,t11;.,. � r <br /> w H uler Name 5 I� Q r I ( <br /> Stamp'Or Llel Off{ <br /> Hauler Telephone Number _ . _ Address Same as Hauler f ,nrf' ISS) <br /> (N 1A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> �'• �' - j - Whole Tires) LAWS OF,THE STATE OF CALIFORNW THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. l <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> a <br /> 4127931 . . - A Pick IUp�� a.Del"ivery <br /> Hauler Tire Program ID i Site SuffixDATE' on, <br /> Facility Telephone Number <br /> _ } nao H1.P/ H9 H7 flo <br /> ( X ora a Whole Tire Count O Weight In Lbs. <br /> ������1nt�.. . <br /> Q V.olumeCubicYds.�WeightinTons Nar�9'"�'�'r0515'7�'\ t�l�e <br /> � - - City• ta#�►aQd,�i t i <br /> o. .Hauler^Name <br /> U �� (1j'..► tQ t\ , t�'"� L� Stamp or Label OK <br /> a Address Same as Hauler <br /> Hauler Telephone Number Initials <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> ``,�.n•� ` {[y\ f <br /> (NIA for LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> Whole Tire O INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Y <br />