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Toll Frei. 6-896-0600 /www.ciwmbeCL_ -ov/Tires/
<br /> California Integrated Waste Management Board
<br /> CA Comprehensive Trip Log and Receipts i000z P.O.Box 1259,Sacramento,CA95812-1259
<br /> Com rehensive Tri Number
<br /> tEx A., n L . x 3 - ._ � 344532
<br /> INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE e
<br /> CIWMB 203(10105) the signor(s)ars request that the Intorma6on rov T on this form S be conaltlered conlldenlial,proprietary antl trade sauet.In nccordan wnh nre,'la ,
<br /> By signing this CA Compri'made Tripdi Loo one Receipt,iign O r q P
<br /> By si at seq.,It a request et mee•for disclosure of this tthe siglon,the GW MB will contact the signegs)of this form r the address and telephone number provided on this form or receipt
<br /> e is e n bt7na Hauler Address
<br /> DLA-San Joaquin Installation Support
<br /> Business Name
<br /> PO Box 960001
<br /> Address
<br /> City, Siete and Zip Environmental Office 16 Mezz
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<br /> I certify under penalty of perjury under the laws of the State of Califomia that the inPonnabon provided above is true and correct In addition,I am aware utet falsificatlan oP,lhis Informati n may result in suslion pesia y revocation,or dental of renewal of m(
<br /> Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penailles up to$25,000 per day,per Wdphtln or administrativt.penaeies up to$5,000 per violation per day as described In Public Resources
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<br /> I�CERTIFY THAT UNDER PENALTY OF PERJURY OF THE
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<br /> LAWS OF THE STATE OF CALIFORNIA THAT THE
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<br /> Hauler Tire Program ID ! Site Suffix DATE:[]o _
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<br /> CL D Whole Tire Count, Weight In Lbs.
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<br /> ;. I _ ,�,I �✓",.,I I ; ~ [� velums Cubic Yds.Q Weight In Tons DRMO Stockton/French Camp
<br /> 700 E. Roth Rd. Bldg 5-3. Box 37
<br /> French Camp,CA 95231
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<br /> I CEHrIFY fHAT UNDER PENALTY OF PERJURY OF THE
<br /> LAWS OF THE STATE OF CALIFORNIA THAT THE
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<br /> INFORMATION PROVIDED ABOVE IS 1AUE AND CORRECT.
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<br /> m PO Box 960001
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<br /> _ Q Stockton, CA 95296
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<br /> ,• �� I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE
<br /> LAWS OF THE STATE OF CALIFORNIA THAT THE
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