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Toll Frei-. -6-896-0600'/www.ciwmb.ca )v/Tires/ <br /> California Integrated Waste Management Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 <br /> "••.-- t L E t 2 <br /> om rehensive Tr► Number <br /> -•--- � <br /> .•••a• _l� /1 ifTt r� .. _ .W ufi <br /> Sanol C4rHoe �•�••••.�.. ar r {I { 1e f Myfy��jr <br /> G1YAPs 203(1 INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE Iw .a , <br /> By signing this CA Comprehensive Trip Log and Receipt,the signers)request that the information provided an this form will he considered confidential,proprietary and trade secret.In accordance with Title,14 CCR,Section <br /> 17041 at seq.If•request is made for dlscle,ii—of this Information,the CIWMB will contact the signers)of this form et the address and telephone number provided on this form or recelpL <br /> Yehtc a nformation <br /> Hauler Address <br /> DLA-San Joaquin Installation Support <br /> �.� <br /> Business Name <br /> °" Address PO Box 960001 <br /> �. : �� City, State and Zip Environmental Office 16 Mezz <br /> A , `� p�?MrWM�Mtl{ ufY>• 39'NIQE�Yf Mn 1YA 8 <br /> Stockton, <br /> CA 95296 <br /> iE'1'G:, � <br /> I certify under penalty of perjury under the laws of the State of California that the information provided above Is true and connect.In addition,I am aware That falsificaiion of this informatldn may.result in suspension,revocadon.or denial of ranewal of the <br /> Waste Tire Hauler Registration pUrsuam io Public Resources Code section 42960 and may result in Civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,009,PeTviofation per day as desutbetl in Public Resowces <br /> Coda section 41952 r 1 . <br /> Driver's Name(print) Driver's Signature^ Date <br /> Comprehensive • •• Number • • Information Facility Tire Program 11 Site Suffix <br /> �lFnLLx <br /> w taF a+ <br /> 6!• <br /> Hauler Tire Program ID / Site Suffix y, Facility Telephone Number <br /> h � � aoo-aoa <br /> Q a a a <br /> -- � " 4a <br /> w . <br /> ri <br /> F1 A,~--Irssa Sams as�'auitr Initials <br /> T. <br /> CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> { S,+w YAH fn n44. t eft v4 k Md HA 1d Tt C�fi3 P°An44P <br /> ... d,%p�!'A4��W�tY "'�°"i LAWS OF THE STATE OF CALIFORNIA THAT THE L INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> a:*r>nt <br /> Comprehensive Trip ••-Number Load Information Facility Tire Program ID Site Suffix <br /> arxi <br /> m ww <br /> R 3434531 -- B esu ` Qel,ve <br /> aoaoaa-ao <br /> Hauler Tire Program ID / Site Suffix Facility Telephone hone Number <br /> g: �a oaa®oa00000 <br /> '+'1?Wt? <br /> !este I ac 3t�5 �t� Ylttk:,. wr, 1f <br /> oil x14--I. XcSC3rrrejDut�[C Yc�skL rnaA i DRMO Stockton/French Camp <br /> ,;aster i-i�.zrr,e: <br /> " "`""`" r"X "'°"I """mo ""'` ""` 700 East Roth Road, Bldg 5-3, Box 37 <br /> 'a� r French Camp,CA. 95231 <br /> mr Hr'l1ier a! .nasy, v ar ww 1 rrt p., ji—�1id-ro i sa:a!a"HzI!c <br /> Inlflal9ph�rFs Ywi»�! <br /> ki <br /> r: 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE T.. <br /> r1rl.,w n�xuw,a.,.'. `ntxnrn INFORMATION PROVIDED ABOVE 16 TRUE AND CORRECT.` � <br /> ComprehensiveTrip Log Number Load,Information <br /> Facility Tire Program ID Site Suffix <br /> 5 L <br /> a. <br /> Hauler Tire Program 1D / Site Suffix "DATE � a � Facility Telephone Number <br /> is .'W"�llflhofe Ttre Cotlpt;,r E!W�tg'11�In,CBs„r <br /> ooa�-oaa000a <br /> �. w t I DLA-San Joaquin Installation Support <br /> aI , I- I �� alumeublc Ytiswelght togns': PO Box 960001 <br /> Environmental Office 16 Mezz <br /> Stockton, CA 95296 <br /> r..Fr ix; ; ., M2 :5a awe:.., x :l M..:, <br /> - ...,J � '� Initials <br /> CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br />