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.... <br /> =:::•.•••.•. 'Cfomii Integrated <br /> Board <br /> Waste Management Comprehensive p Log and Receipts 15Sacfento CA581 <br /> 2 11259 <br /> E jX A1M P t» E; 2 3 Comprehensive Trip Number <br /> remJ ' <br /> rnabb1�fsMIirncdcdas)INSTRUCTIONS ON BACK OF PART 2 bo NOT TAPE.STAPLE`OR DUPLICATE <br /> By signing this CA Comprehensive Trip Lop and Receipt,the signer(s)requasl Uul the information provided on Ws form will be considered con1fdentiai,proprietary and trade siereL In accordance with Title,ff CCR,Secden <br /> 17041 al soq.,Na request Is made for disclosure of this Information,the CIVIMB wR1 contact the signers)of Ude form at the address and telephone number provided on this form or receipt <br /> • " leis taftf"[ii"titin ��r��,: £ � .. <br /> Hauler Address':' i <br /> Vett <br /> i3us(ness Mame <br /> 7 ti, <br /> Address <br /> City, State and Zip <br /> - � u.je•vc c��Z� 9.� `i��� <br /> {J C Common. _ <br /> Carrier . <br /> I car*under penalty of psrjuy under the laea of the State of CaWorria that the infoimifod provided ebo•re Is We and correct in add;t1en.I am aware that fa'sihfalLfi tWs Womadon may neurit h suspension,rayora8on.or denal of renewal of ih <br /> 1Vasts Two Hauler Re¢sbafon pursuant to Pubfio Resources Code section 41960 and may restft In cM pena8as W to S 25,000 per day,per•Baton or penat;.eaPip to$5,000 per violation par day as dascnbed In PubFo Resources- <br /> Code seeon42962 <br /> �L e--f-r j.CJw✓��-t�X1 A) � ` <br /> Driver's Name(print :> v_ hr's; _igrlature <br /> 3248624 C O � U0 � <br /> t� Facility Telephone Number <br /> Hauler Tire Program ID I Site Suffix I <br /> I I,, `r`r�) *;i <br /> 'f <br /> F zcility E3ilsine <; <br /> ee� air�ptAddtess <br /> Hauler Name ly :Mate rinif lip <br /> Stamp or I Ojol OK <br /> Hauler Telephone Nuinbei <br /> IOU <br /> ❑ Address.Same as Hauler rNrftals <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> DEO ABOYE 9 UE AND CORRECT. <br /> • • •a •' e.•11 fil[aid • • • <br /> 3248624 "" B �� N 0 Ub ❑. t� -0 0 <br /> Hauler Tire Program ID 1 site suffix Facility Telephone Number. <br /> goo aooaoao <br /> ��h litt3usirr++�s,s ii L <br /> L { 7 `l, eaa• f <br /> ,?r <br /> al, <br /> t �e?•S' 7~ct �:� <br /> Hauler Name (2�j,&I61. 4Xt1t)•fV f{-'v< <br /> Haulei}i elephone Nuni6er r,1. f� ❑ Address Same as Hauler fae)•f• —I <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORNIA.THAT THE <br /> ac- <br /> 3248624 <br /> ,r1- <br /> J /.) DIF ON PROVIDED ABOVE M TRUE AND CORRECT. ,•ic <br /> 3248624 ® A a ® -❑ <br /> Hauler Tire Program ID ! site Suffix Facility Telephone Number //rr <br /> Fa i�u-in s <br /> I N <br /> .. <br /> auler N ie <br /> Hauler Telephone number `� ❑ Address Same as Hauler ,nrfrafs <br /> f CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> • r.-}�� /�r -J LAWS OF THE STATE OF CALIFORNIA THAT THE ;] <br /> INFOfiMAT10N PROVIDED ABOVE ISTRUE AHO CORRECT, t <br />