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-- <br /> ifornia <br /> Board <br /> CA Comprehensive . aip Log and Receipts ioo�. CalO.Box1259,Sadainef Management <br /> P.O.Box 1259 Sacrainenlo,CA 85812 .1259 <br /> � X P t Com rehensive Tri Number <br /> �___ - <br /> il��"s <br /> cIT1Tfa29j(fa90INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE <br /> By signing this CA Comprehensive Trip Log and Receipt,the slgner(s)request that the Information provided on thea form Will be considered CongdentlaiL prepdatary and trade seutL In accordance with We,14 CCR,Secdort <br /> 17041 at saq.,H a request Is made for disclosure of this Information,the CNIMS will contact Ue slgner(t)of We form at the address and telephone numbarpeavided on thistorirra recalpt <br /> FA" Vt3tfcte fnfo'miatio� :: <br /> t 1a Hauler Address <br /> Business Mame <br /> Address >..�� / c� c�4:) <br /> U City, State and Zip <br /> - x� �'Gc�r<ti•G.. `fir `} y' `i�/� <br /> cc) <br /> eCrrIfT1UI1 <br /> Carrier .. <br /> I teddy under penahy of perjury under the IaM13 of the State of Catforrva that Che Inioimaf-on provided ebore 13 tme end correct In addition,I am aware that fa'smy'+tbf-c dds Mirmation may nsul!h su;pen4'ori,!eyoceYan.or derdal of rene,raf W the <br /> {'taste Tire Hauler Reg:stradon pursuant W Public Resources Code section 42960 and may resu.t a1 de![pens des W ro S 25,000 per day,per viola:on orad s peneI' T'P to$5,000 per violation per day as described In PubFo Resources <br /> Code section 42962 <br /> Driver's Name(print) �� ver's <br /> Dae.. . <br /> tCjnature . .�•: <br /> •. •.• • -1111111111 <br /> 3248624 -- ❑ <br /> aaoad000 <br /> -� Facility Telephone Number <br /> Hauler Tire Program ID ( Site Suffix t <br /> o®aoaoo � � <br /> Qa <br /> i=' ciiity SI siness <br /> arrle/Addr(ns <br /> ( ly z <br /> Hauler Name State all( <br /> - ;tamp or Label OK <br /> Hauler Telephone Number Yr ❑ Address Same as Hauler Initials <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> • LAWS OF THE STATE OF CAUFORHIA THAT THE <br /> DED ABOVE ISJRUE AND CORRECT. <br /> 51 <br /> 3248624 'B ❑ ❑ �� o❑ �� o-aa <br /> Hauler Tire Program ID 1 site Suffix Facility Telephone plumber <br /> � <br /> Il,t,,,a,(usi17 SS (\ <br /> L ( r' tV 1111?f1(7C'IrG'S <br /> Hauler Name (. 5�.(S�1m,)l gilt)fv <br /> Haulei�l elephone Number �� v ❑ Address Sante as Hauler lnlnars <br /> CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORMA THAT THE <br /> INFORMATION PROVIDED A13OVE IS TRUE AND CORRECT. <br /> 324 <br /> _8624 -- A �: aaoo(aao <br /> Hauler Tire Program ID 1 Site Suffix Faculty Telephone Number <br /> oao <br /> Faffalit <br /> 'a r ® 0,I <br /> aider Name <br /> Address Same as Hauler <br /> Hauler Telephone Number `� l ❑ Initials __1 <br /> Q CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE _ <br /> % IHFORMATIOH PROVIDED ABOVE IS TRUE AND CORRECT. �`"` <br />