Laserfiche WebLink
Waste <br /> is <br /> CA Comprehensive Trip Log and Receipts 10002 California 1259,Sacramento,CA <br /> 95812-Board <br /> P.O.Box 1259,Sacramento,CA 95812—1259 <br /> 0X AIM P LIE1 Z. 3. Comprehensive Tri Number <br /> ScilvMemij)oros�INSTRUCTIONS ON BACK.OF PART 2 DO NOT TAPE, STAPLE OR:DUPLICATE 3 2 4 8 8 6 9 <br /> By eigning this CA Comprehensive Trip Log and Receipt,me signar(s(request that the information provided on this form will be considered confidential,proprietary and bade seveL In accordance with This,14 CCR,Section <br /> 17041 at eeq.,If a request is made for disclosure of this Information,the CIWMB will contact the eigner(s)of this form at the address and telephone number provided on this form or receipt <br /> V,etiicI-el In 07rmation <br /> Truck Decal Number Hauler Address - <br /> Business Name <br /> Address . <br /> City, State and Zip f'-U 4- ; <br /> License Plate Number State <br /> ® � a © a a o o � El Common on _I �Lt.yLti/G o�'/ � }'.r�Yd <br /> 1 certify under penalty of perjury under the laws of the State of Califomla that the information provided above is true and coned In addition,I am aware that falsirication of this information may result in suspension,revocation,or denial of renewal of m <br /> Waste Tum Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to S 25,000 per day,per violation or admi"e roe 0walks up to$5.000 per violation per day as described in Public Resources i <br /> Code section 42962 / ' -� <br /> G�� W__ SSS-yip -✓ 1 '? ' � --- 0YL <br /> Driver's Name(print)' DKiver's Signature Dates <br /> Comprehensive Trip .. Number Load Information Facility Tire Program <br /> i <br /> 3-248869 -- C� Pick Up ElDeliveryCD <br /> ID <br /> ` c Facility Telephone Number <br /> Hauler Tire Program ID / .Site Suffix DATE � / {®� / ❑ <br /> - aoo-o ❑aaooa <br /> w © Whole Tire Count Weight in Lbs. � <br /> ° Ir i yB�Sin Y <br /> EI lop r ( � 0 Volume Cubic Yds. Weight in Tons FW <br /> I"dres <br /> $ Hauler N e <br /> a ■ Address.Same as Hauler I <br /> Hauler Telephone Number ❑ <br /> ( <br /> (N/A for I CERTIFY THAT UNDER PENALTY PERJURY THE IniF71 , <br /> tials Whole Tires) LAWSOF THE STATE OF CALIFORNIAI THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> 'te Suffix <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Sl <br /> comprel <br /> 3M8869 4 8 8 6 9 B Pick Up Delivery © � ® a © ©-H <br /> as <br /> WO Hauler Tire Program ID I Site Suffix Facility Telephone Number <br /> y DATE / / �®. _. . _ <br /> w Weight in Lbs. ❑ ❑ .� a a ❑ a a <br /> M LU f® Whole Tire Count 9 UW1'J%2dr!*ss � <br /> � G) 6-O VolumeCubic Yds.❑Weight in Tons I <br /> o HaulerONNme. V!��ate�Z��( S <br /> �f !I� <br /> SS g6habe6e K(� 72 <br /> Hauler Telephone Number- ■ _❑ Address Same as Hauler Initials <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> (N/A it If AWS OF THE STATE OF CALIFORNIA THAT THE <br /> Whore Tires) <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID. Site Suffix <br /> 3248. 8 6 9 A. Pick uP ❑ Delivery1 M HE ® LJ_� <br /> Hauler Tire Program ID t Site Suffix Facility Telephone Number <br /> y DATE <br /> NP] <br /> _ _ MEE ©000 ❑ o� <br /> W ®Whole Tire Count Weight in Lbs. t <br /> D b ❑Volume Cubic Yds. Weight in Tons N ne/Add ass <br /> Et � 3 g <br /> o Hauler Name ` e� 52� <br /> Iw- <br /> Q, NE a yl�r e VS3R�L�} �2. /Z05,! <br /> 4<� <br /> Hauler Telephone Number a ■ ❑ Address Same as Hauler Inrr/als <br /> (N IA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Wh01m Tires) AWS THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. / (� <br />