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9060 '°N Wd97 :ti El06 '0l 'Oa0 awil paAiaOa� <br /> 1%-"[ F-11 r Vnwen:c1VV"tw: <br /> ya ate° California Inmgrdted Waste Management Board <br /> C <br /> - .� 01omprehansi re `rap Leg and Receipts 10002 P.O.Box 1259,Socramonto,CA 95312-1259 <br /> Comprehensive Trip'Number <br /> INSTRUCTIONS O1�6 $,'-1CK �:F 1�!'+IRT 2 DO MOl"TAPE, STAPLE Oil DUPLICATE: 4 C'`r'917 4 <br /> a1vuea i� em <br /> By <br /> .IF"ItU thla CA Cpl.h..Na Trlp Lori and Roeolpe the s�n,nr(s)req ea•3Ole•.Ula Wo-11-pr-ldoe Fro tnb form will wco-Id-4eoandontial,propriewy and trade secret In aceordanco wren nue,14 elft,UcDon <br /> 12,41 ctaaq,If a roq—t b made lar di-I—re,o/M Infonnadon•the CTAW.B wHI <br /> ccnawt the slarloRa)of Mb Torn at the addrvaa and Wlophona nomh•t provtded on this tom,or race of <br /> --- — veh)cle Information <br /> Truck Number <br /> Decal Num <br /> as o oell <br /> License Plate Number '.State <br /> 0 o ao as-� • a � . - -_____-_ ___ <br /> i.^^^..li cn��ar LC?]Ty el p:-.,n;_nd?'•'ra IJm•.;J InE S'➢I-'I C".1,-.,.: L. :Ic' ]1 en pmVi$^a JCw^_is eco CJTNW In OdUltieq.t em JHSTo m,fawn-Ii-al Inn —cm—x I—t e:rer.•:+.m o:rn <br /> `::Jr',.T,ivH. .:.-v'Y:•.1':r.._..1..,�F,,_I:.?..:V.III:, ink:"-. , ,�- rKWi.n C•il rw n.: i. 25 317 •.C '..,-- _'.l]'•n:!:,,:'.:F<nJl:`::p t:S:.007 J,..I l.lnn rJ. '1:•..1.0:..t,..101 Cr11 •:�." <br /> Driver's Name(print) Driver s Signature Date ; <br /> 7H.,1,.rTirePrograrmnIC79 _ -; l aa � oa � ��ao , <br /> 4, '—I Pick Delive n <br /> ; ._ I I Site Suffix f Facility Telephone Number j <br /> 3A I F] <br /> I V., Whols Tina Count lM1/olghtin Lbs.. <br /> a � � ooaoa � a <br /> m Volume Cubic Yds.F1 y'1reight In Tons <br /> a <br /> - - (N!'.1 for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whoie Ttrew CAWS OF THE STATE O^CALIFORNLt THAT THE <br /> d�. INFORNATION PRCVUD�ABOVE M TRUE AND CORRECT. <br /> a • mivr4 rr':- • a <br /> O �JO ��O � <br /> Q 4 0 7 917 �? � ' r Pock lDP delivery I 1 <br /> s Hauler Tire Program ID ! Site.Suffix n <br /> Facility Telephone Number <br /> ;�s�TE a1L_II �a oa .q <br /> w saa -oc � aoc <br /> M �'El w6oie Tire Courrt -❑Valeight Jn Lbs. <br /> y I I Volume Cubic Yds. Weight In Tons <br /> �-DHH <br /> l (N 1A rot t t CERTIFY THAT UNDER PENALTY OF PERJURY OF THE _ <br /> whole Tlroa) LAWS OF THE.STATE OF CALIFORNIA THAT TFIE y <br /> INFORMATION PROVIOMD ABOVE 19 TRUE AND CORRECT. <br /> e `�Mul, <br /> n <br /> 4. 0 7 Q'� ? 'iCk Up Deitvelry0 E 110 0 E 0 <br /> 41 <br /> Hauler Tire Program 11) 1 Site Suffix FIE <br /> Facility Telephone Nurmber <br /> [1 . ao_ oar ao � o � ao <br /> rc Lt4 1PVtso1®Tire Count ,�Vleightin Lbs. <br /> a.. „ —.. <br /> tw. Volume Cubic Yds.❑Weight In Tons <br /> a <br /> w <br /> 0 <br /> H ,.. •' I CERT-FY THAT UNDER PENALTY OF PERJURY OF THC <br /> LAWS OF THE STATE OF;CALIFORNIA TFIAT THE <br /> p �ni'Ml WFORMATtOtr PROVIDED ABOVE LS TRUE AND CORRECT. <br /> JGAJGS XleA Z00/Z �10V`d Wd 00 : ZZ : L ET0Z/0T/ZT JOAX99 Xle,4 <br />