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California Integrated Waste Management Board CA Comprehensive Trip Log and Receipts 10002 o.Box,25g,Sacramento,CA45e,2-,258 EIX AIM P EI '111'2131 Com rehensive Tri Number crwnfe�j nnsl INSTRUCTIONS ON BACK OF PART 2 'DO NOT TAPE, STAPLE OR DUPLICATE; 3682-8.3.3 By signing this CA Comprehensive Trip Log and Receipt,the signer(a)request that the Intonation provided on this form will be considered confldential,proprietary and trade secret.In=1 dance with Title,14 CCR,Section 17041 at seq.,H a request Is made for disclosure of this lnformatlon,the CIWMB will contact the eIgner(.)of this form at the address and telephone number provided on this form or recelpt VeFiiclellntormation Hauler Addressa� 1A Truck Decal Number Business Name �D ' G ,( Address �J City, State and Zip License Plate Number State l _ L7J © ® ® ® ® n ® El Cao rriern. _�,�J I certify under penalty ofALN der the laws of me State of California that the information provided above Is true and correct.In addition,I am aware that faisrl Uon of this information may result in suspension,revocation,or denial of renewal of dm Waste Tire Hauler Reglsmuanl to Public Resources Code section 42960 and may result In Civil penalties up to$25,000 per day per violation or aim str�bve rm10es up to$5.000 per violation per day as described in Public Resources Code section 42962 ! �/(� (V f l•1 bf, 'a 7 "'t f iai y t q , Driver's Name(print) Driver( "Signature Date . .. .. ram ID Site Suffix 3682833 C Pick Up Delivery. U i, �j Hauler Tire Program ID,/...Site Suffiph x Facility Telephone Number j DATE I�UUU ® ao o� oao � � w�Whole Tire Count F]weightin Lbs. a �-�-- f Facility Busines�=�� od a A Volume Cubic Yds ❑Weight in Tons NamelAddressr- � D�/C ��J City, State arteJcl Hauler Name �- U U P,n L �/ / �� a _ Stamp o1-7r OK Hauler Telephone Number ■ Address Same as Hauler Initials i (N/A for j I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE 7S I LAWS OF THE STATE OF.CALIFORNIA THAT THE ` y Z 0-1 C Whole Tires INFORMATION PROVIDED ABOVE ISTRUE AComprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix ND CO RECT. Y ZEL CIL 3682,833 BPickUp ❑ Delivery liHauler Tire Program ID / Site SuFacility Telephone Number � DATE ©� / ®®./ [AZ . i � a �iWhole The Count �Weight in Lbs. to Facility Busi ffix Volume Cubic Yds.�Weight In Tons ,Name/Addie. City:State,a E Hauler Name c . U U A I A-(1_, a Stamp or Label OK Hauler Telephone Number MHE Q Address Same as Hauler 1i1Nal J p 'a IN/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF.HE W_hole T1r06) LAWS OF THE STATE OF CALIFORNIA THAT THE_ INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. ' • • • • s •' • • • • Program 3682 8 3 3 -- A . Pick Up El.Delivery HaulerTire Program ID / Site Suffix DATE ( Facility Telephone Number tg w ©Whole Tire Count El Weight in Lbs. / o- Facility Business �i 7 /L f d tJ'ID Volume Cubic Yds. Weight in Tons Name/AddreJ o Hauler Name City,State a d Zip U « /f .%//. / Stamp or Label OK �1 l' a Address Same as Hauler J Hauler Telephone_Number. ■ ❑ Initials L� -I CERTIFY THAT UNDF.A PENALTY OF PERJURY OF THE Whole TIreS) LAWS OF THE STATE OF CALIFORNIA THAT THE S INFORMATION PROVIDED ABOVE Is TRUE AND CORRECT.