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Gallfolnis Intapratad Waste ManaaanaM Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259.eacrarrwnto,CA96ET2—Iz" <br /> •�•,�,�, r t �. •_'--+ Comprehensive Trip <br /> ri Number <br /> aw.INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE 3957116 <br /> By alpninp""CA C—prehenah.Trip Log end Recolp,tN slpne4s)regtwat that 1M Ireof nwft l pros'ldsd on thb form wM to mw{aw rrcauldenwl prop(§@Wv end trade sacral In accordenes rraf 77*14 CCR,ascoon <br /> •,IM41 at 6046 If a request le mads for dbclwurs of tftb bdo m rlIM the CrNMB vAY eontwl the stW*o)of biW form at ted addrou and blsphow nuillaw provided on thb form err* <br /> 777 <br /> „;:.l.,nye 0 C 9'n rR1B66,M,M1�t tim�l7 I <br /> Truck Decal Number Hauler Address �Business Name � C-C)m eQc 1)I�KJAddress e6��City, State and Zip <br /> License'Plate Number State }� <br /> Common <br /> v��1` t%1 } <br /> Carrierq � -z 2. <br /> I caruty under penalty of perjury under the lave of the Stats of Celllornia that the Information provided above Is true and cor—l.In addition,I am aware lhst falttlff on of lhie Information may mutt In euapenalon,revocation,or denial of mnewal d tn <br /> Waste The Hauler Registration pursuant to Puolic Resources Cede section 421360 and may result in civil pena6ies up to$25,000 per day,per vbletion of edmVJatmtFve penetbes up to$5.000 per vbta6on per day as descrlbed In Public Resources <br /> Code sWton 42962 <br /> ,)6 k !A <br /> Driver's Name mint — Drive s S ture Date <br /> Comprehensive .. Program <br /> x 3 9 5 7116 -- <br /> C. Pick uP Delivery100001100 * 0D <br /> 10 Hauler Tire Program ID .1 Site Suffix Facigty Telephone Number <br /> DATE �DD � DD <br /> DDD-DDDDDDD <br /> A l 1 w ❑ Whole Tire Count Welght In Lbs.. <br /> Facility i3 sines <br /> d ` Volume Cubic Yds.D Weight In Tons Nam /Ad r <br /> ( <br /> $ Hauler Name _ Citye z"� <br /> v � -Stamp or Label OK <br /> a DAddress Same as Hauler <br /> Hauler Telephone Number ! <br /> (N IA for I���THAT VrWFit FE71AL1Y OF FfSldlMtY a THE <br /> YM[N for uwa of THE STATE OF CAUPO MMA THAT THE <br /> Comprehensive . Log Number Load Informationas <br /> a 3�9571�16 -- B Pick.Up Delivery <br /> Hauler Tire Program ID 1 Site Suffix Facility Telephone Number <br /> DATE D® � <br /> a ®Whole Tire Count• D Weight In Lbs. <br /> Facility ,r stnPss <br /> Volume Cubic Yds.❑Weight In Tons NamelA ff f6ot.Commercial Tire <br /> a�4m�T`21 <br /> " City,St �loilcox Rd <br /> Hauler Nems Stockton CA-95215 <br /> vStamp or,L.abel OK <br /> Hauler Telephone.Nurn ■ Address Same as'Hauter <br /> dj'� r�'��) HA <br /> /t`/[� (M IA ftw I COM"TT WCDM PaiALrr op Pautw1'of THE <br /> r L.i !`ti 1 +�y Who"Tlr S)" LAM OR TM STATE OF GALWOMA THAT THE <br /> Comprehensive\ ... 111.. 1 . . Number . . . InformationProgram <br /> 3957116 ,=- A Pick Up El Delivery.10 URN ® P E—© M <br /> Hauler Tire Program ID /.Site Suffix. Facility Telephone Number <br /> DATE @© /U <br /> @� t <br /> tu ®Whole Tire Count []Weight In Lbs: } C <br /> mO V y Volume Cuble Yds.a Welght In Tons m <br /> S P <br /> E y I t R.D <br /> r� alder Name ,r elf, <br /> v� F OT 71 <br /> 0 I� c <br /> Q D Address Sami'f�Uter <br /> Hauler TOophone Number ■ <br /> r1 �] (N!A for I t ItTFY THAT UMDFA PEMALTY OF PeCWUHY OF THE <br /> rVt _` �nom) LAWS OF THE STATE OF CALMORIM THAT THE <br />