COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

ated ste Board SCA Comprehensive Trip Log and Receipts 10002 California Sacramento,CA 95812 1259 P.O.Box 1259,Sacramento,CA 95812—1259 Comprehensive Trip Number EM.AIM P L E11,12131 :.,7., de.a cauramf. .s CIWMR 203(fm05J INSTRUCTIONS ON°BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE 3248374 By signing this CA Comprehensive Trip Log and Receipt the signer(s)request that the Information provided on this form will be considered confidential,proprietary and trade secret In accordance with Title,14 CCR,Section 17041 at seq.,If a request is made for disclosure of this information,Na CIWMB will contact the sig—,(.)of this form at the address and telephone number pravlded on this form or recelpt:•. Vehicle Info.rtmation } Hauler Address Fr�n� Truck Decal Number �%CH•r!'>`-L /�`9�1. �r W S Business Name / to Z Address r- 0:1;.. /3,9 X /O City, State and.Zip 1 License Plate Number - State I ? L y C Common a ® � ❑ © [ Carrier I certify undor penalty of perjury under the taws of Nth e Stale of California at the Information provided above Is We and ecl.In edd,uon;l am aware that falsinca .f this information may result in suspension.revocation,or denial of renewal of IN I' Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil p per y.per p per vi y penal0es u to,5 25,000 r da r vioWtion or adn' a penaltles u to$5.000 dation per day as described in Public Rasaurroa Code section 4296 Driver's Name(print) D ver's Signature 6ate Comprehensive Trip . . Number Load Information Facility Tire Programi I c 32;4 8 37 4 -- (i Pickup Delivery a MOR2 Hauler Tire Program D / 'Site Suffix Facility Telephone Number i g DATE nZoa-®oa © a® © Weight in Lbs. Lu @'Whole Tire Count g Vel �it1�sine, y b 01;-I3 3 6 -m- Q l F" Volume Cubic Yds.1:1 Weight in Tons Maplel, ress� E P C' Aftan4gip <C�( 1 V', ('➢•,1 w Hauler me d StaR�clg4 CA- Hauler A- U l � � Q Hauler Telephone Number O ■ E] Address Same as.Flauler Initials (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE „ INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix .3248-37'.4 .. ' 'tl. BrATE Pick up El .Delivery EH 9N &W-1d V1 I Hauler Tire Program ID / Site Suffix / Facility Telephone Number _ c .. .J Weight in Lbs. M { Whole Tire Count ❑ 9 i ,,ll {{ F� siness a) V V Z � a 1Volume Cubic Yds. Weight in Tons E Cit 4a43dlzi = Houle erne vt Stamp Hauler Telephone Number ■ Address Same as-Hauler / ^-\ (N(A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS OF THE STATE OF CAUFORNIA THAT THE 777 INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffixi 3 2 4 8 3 7 4 A Pick UpEl Delivery o EH [AU/ 0H-' H o X Hauler Tp* a Program ID 1. Site Suffix Facility Telephone Number .. � � DATE r , . 4 a � ® oo© a000 . Lu ®Whole Tire Count Weight m Lbs. fFacilit siness 0 61 o Volume Cubic Yds.a Weight in Tons flame/ E Hauler N e CitX, �n .Zip t. F t n I S atnp� a V Address Same as Hauler ' initials Hauler Telephone Number ■ I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE .f1L �O / 7 (N lA for IAVIS OF THE STATE OF CALIFORNIA THAT THE fI? Whole Tlfee) INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.