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rt <br /> CA Comprehensive Trip. Log and Receipts 10002 Calrfox1259.SedWstarlC 95612-12 9 . . <br /> P.O.OBoz l. Inbar ted w shk an gerne—7269 . <br /> ;;;;: X(A ed. E_ C . 1 2 {3 - <br /> Comprehensive Trip Number . <br /> c>t►>�xnrya�INSTRUCTIONS ON BACK OF PART 2- DO NOT TAPE,STAPLE OR DUPLICATE `� U 015 <br /> By slgning this CA Comprehensive TAD lag and RsceIK dw•Ipna(•)request Net the Irdotmatlon provided on this lions will he consldsnd confldentlaL proprMYry and cads secret In accordance vAUr•TSY,14 CCR,Secdon . <br /> r 17041 at w q.,It a request Is made for dbebsur•of this m(omutlon,1%CIWNB vital contact the slgntai of this form at the address and A•ISPhone rrtanber Provided on the,form or reenlist .. .. . <br /> ehic a nformation `? } <br /> Truck Decal Number Hauler Address <br /> Business Name C l V <br /> ©• a _ Address U <br /> City, State and zip' <br /> License Plate Number State <br /> r` Common <br /> 0 Carrier <br /> certify under penalty of perjury under the laws of the State of California that the information provided above is We and correct.In addition,I am aware that falsification of this information may result In suspension,revocation,or denial of renewal of th <br /> .. Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties uplo y 25.000 per day,per violation or administrative penalties up to 55.000 per violation per day as described in Public Resources <br /> Code section 62962 /� <br /> 177r/'JAL C rl'a f ,t a i;k .. � .. - 3• -0 // <br /> `, { <br /> �► e c -�v <br /> Driver's Name(print)- Driver's Signature - Date <br /> Comprehensive . . . . . . . g Site Suffix <br /> 384 6015 .. - C Pick Up Id Delivery <br /> Hauler Tire Program ID l 'Site Suffix DATE Facility Telephone Number <br /> ED / aa ©a <br /> c. . w Weight <br /> ■ � Whole Tire Count In Lbs.� <br /> I"aew usi,a <br /> a. <br /> .Volume Cubic Yds.a Weight.In Tons Nam f°. - 5�/�-CRrt1 <br /> o Hauler Name C°fy tJie 3jd PVS p� <br /> w / Clv <br /> U $t p 3F L <br /> Hauler Telephone Number ■. Address Same as Hauler , � <br /> (N/A for 1 CERTIFY THAT UMBt PENALTY OF PERJURY OF 711E <br /> Whole Thal) LAMB OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE 18 TRUE AND CORRECT. <br /> JIM <br /> RL <br /> 3846015-- - Pick Up ❑ Delivery <br /> oa0000 <br /> Hauler Tire Program ID / Site Suffix .DATE / j ! Facility Telephone Number <br /> ©© a© as <br /> - ado-aaoo © a <br /> a Whole Tire Count Weight In Lbs. <br /> �ca kky S5t !ney^a� . <br /> m ❑ Volume Cubic Yds.a Weight in <br /> Tons MCI o ass <br /> E Hauler Name. <br /> C1 a J <br /> S4or <br /> Hauler Telephone;tUulTiber 1 ■E E 0 Address Sarrie as',Hauler <br /> (N/A for '.I CERTIFY THAT UNDER PENALTY.OF PELAIRY OF THE <br /> RNN . <br /> . Whole TLea) LAWS OF TIF STATE OF CJWFO .THAT THE. . <br /> �,. RIFORYI1TIOp 'ABOVE B TRUE D CORRComprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> ECT. <br /> I' <br /> a 3 8 4 6 Q 15. -- A Pick Up ❑ Delivery 0 © 9 <br /> m <br /> o Hauler Tire Program ID / Site Suffix DATE ne Number <br /> 3 / , / Facility Telephone. ©o a® oa _ <br /> . oo� <br /> Ro Lu Whole Tire Count Weight In Lbs. � <br /> m I I o I Volume Cubic Yds. Weight in To <br /> oHauler Name C <br /> Hauler Telephone(dumber ■ E] Address Same as Hauler <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF TM <br /> Whole recce) LAWS OF THE STATE OF CALIFORNIA THAT Tiff / <br /> INFORMATION PROVIDED ABOVE 18 TRUE AND CORRECT. <br />