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��'+'+. Comprehensive <br /> qy �p I��1 Log <br /> ��q r P� Receipts <br /> � ,?+ $ California Integrated Waste Management Board <br /> CA Comm l ei l ensi e T ,l, Lo and ;(` ecei Ys 11 0®0'2 P.O.Box 1259,Sacramento,CA 95812-1259 <br /> : 1 .� y° i $' _._-_ �'�" �, Comprehensive Tri Number l <br /> Q- <br /> st.t.&C.11f."' <br /> 3 3459 <br /> WM0 (101CIWMB /05)INSTRUCTIONS ON BACK OF PANT 2 DO NOT TAPE,STAPLE Ofit DU PLICATE f <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 /> 17041 at 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 on this form or receipt. <br /> Vehicle Information Hauler Address <br /> Truck Decal Number Business Name f <br /> 0 0 Defense Distribution Depot San Joaquin <br /> Address <br /> City, State and Zip P.O.Box 960001 <br /> r License Plate Number State DESJC-PSS,Bldg 16B Mezzanine <br /> `�R ® ® Id [JOE 110 ❑ Carrier <br /> I Stockton, CA 95296 <br /> "arriet� L <br /> I certify under penalty of perjury under the laws of the State of California that the Information provided above Is true and coned In addition, ware that falsification of this inform may result in suspension,revocation,or denial of renewal of the j <br /> Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to$25,000 per de er vi atlon or administrative pe IOes up to ,000 per violati n per day as described In Public Resources <br /> Code section 4 2 <br /> Driver's Name(print) Driver's Signature Date <br /> C Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 3 4 3 4 5 2 9 ®� ��C� up Delivery 0 110 0 0 0 D-E 0 <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> � DATE <br /> Lu inLbs. <br /> 00 <br /> Lbs. 000000 <br /> � <br /> a � Whole Tire Count �Weight In <br /> a ~ Volume Cubic Yds. Weight in Tons NameiAddk mss <br /> E Hauler Name 'ity 'tate and Zip <br /> a Stamp Address Sante as Hauler <br /> mauler Telephone N3rtaer 00000000 Initials <br /> (N/A for (CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) =THE THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> i I <br /> Q <br /> 3434529 -- D)< Pick Up ❑ Deliveryar <br /> � 00000 � 00 <br /> Hauler—tire Program ID / Site SuffN �� Facility Telephone Number <br /> DATE <br /> RC? P H <br /> M w ( Whole Tire Count Weight in Lbs. <br /> 000000 <br /> a I Defense Distribution Depot San Joaquin <br /> 1 (0101641 t/ i ~ ❑ Volume Cubic Yds. Weight in Tons P.O.Box 960001 <br /> E ~L�ler Name DESJC-PSS,Bldg 16B Mezzanine <br /> y Stockton, CA 95296 <br /> v Dl .. J — /— C'-I' <br /> DOER <br /> HID]A;- rpt1,n r t e ess Same as : -- <br /> Initials <br /> (N!A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE r <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. �! ` <br />