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Caflfltrnla Intaprabed Waeta Management Board <br /> CA Comprehensive Trip Log and Receipts 10002 eom Comprehensive TripBNU—1269 <br /> Number <br /> M. > X A NtIPILI 3 _.. .� <br /> If"xy(lgINSTRUCTION5 ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE 3956961 <br /> DY sipnlry�IAh CA Cane ttxwM Trip Lop wW Rralpt,the @Wna(s)rpuat dW the Inlwmsgon pwM.d on this form wM M oomMasd +1.P�P'Md'tt secrM.In.ceoMvtc.w1a+11W,14 CCR,e.cUon <br /> 17041.t seq.N a r•quee is mads fm discloauas of d"brkwm&dM ttw C1Wl*to coldest the slprt0s)of thea lam at th•addren and blaptwM number provld•d on this form or reeslpL. <br /> a'4_!m o n��, commercial ire <br /> Hauler Address '''; Wingfol) Com <br /> Truck Decal Number Business Name ''© ® si Street Address 1400 S.2� <br /> AR 72901 <br /> City,State and Zip F car;Smith <br /> License Plate Number - State <br /> a9KIDoo, © ® ��rin� <br /> I lenity under penalty of perjury under the laws of the State of Calif—i.That the Infonrmtion Provided above Is m,•and coact in addillon 1 em aware amt ta*Mcatlon of this odor Wn moY result In suspension,ma tylion,or denial of renewal ot'.h <br /> Waste The Hauler Registration Pursuant to Public Re•,u+rce iCo�daa section AZM end may rents In"penattNs up to$25,000 p•r day,per vtdladeathe on or adminlsp•naltlea uP to WON per violation per day as described in Public R... <br /> Coda section•206 I,1� C)`A I,-\1 ►'►r, L7 <br /> Dfifers Name <br /> T Drivers SIg ri re ` ,Date <br /> rant <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> �' Pick Up Delivery ❑ ❑ 0_1� F1 3956961 ❑ ❑ ❑ ❑ <br /> Tire Program ID ! Site Suffix Facility Telephone Number <br /> Hauler ThOATE Do / <br /> ❑❑ / ❑❑ <br /> C� <br /> w ❑ Whole Tire Count, Weight In Lbs. <br /> ❑ 0D-❑❑❑ 0 ❑ ❑ ❑ <br /> [TelRitg Eusincasss <br /> m Volume Cubic Yds. <br /> Weight In Tons A!a alAddr 5 <br /> ErHaulere CitiStamp or Label OKkhane Number ■ <br /> Address Same as hauler --J <br /> (N IA for i CttRTiFY THAT IJIQER PENALTY OF PERJURY OP THE. <br /> Vadis ATIMI LAWD CW THE STATE OF CALIFOW THATTHB <br /> . • • Log Number Load Information Facility Tire Program <br /> 1 �e B Pick Up t D®livery n n ®— <br /> _ 395696 © ❑ ❑ ❑ <br /> Tire Program ID 1 SRO Suffix nn - Facility Telephone Number <br /> Hauler Th <br /> U P H R 0 H N R R E <br /> DATE W / © - 0® <br /> U, ®Whole Tiro Count Weight in Lisa. p <br /> d o p Volume Cubic Yds,❑Weight in Tona ��ty <br /> rrt� i�3aommercia! Tire <br /> {� � ox ltd <br /> Hauulefr(Name. 5 ocktort CA 95215 <br /> Stamp 'or Label OAC i <br /> Hauler Tele have Number ■ ❑.Address Same as Hauler <br /> P 1 COMFY TtiAT UNDOt PENALTY os Prlt,riutY oF.Tlm'. <br /> �j�}1 �/�} (N lA for <br /> w/ 1 t '! Whole�lwa!- LAM Or THE STATE OF CALIFORMW Tt1AT THF: - <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 3 9 5 6 9 61 . _tom A Pick Up El13e11veryC 0 g 5 RN H-0 H <br /> Hauler Tire Program ID I Site Sux DATE Facility Telephone Number <br /> . ffia® � �® .� <br /> @H & noOHS <br /> w ®Whole Tire Count OWeight In Lbs: s nes <br /> � E[",a, -n r�7"G 5 <br /> O ` _ ❑Volume Cubic Yde.❑Weight in Tons �Ad� s p� <br /> LL•� � Hauler Name _ C�®�e.• �1-�'�T�� R-D <br /> Hauler Telephone Number ■ ❑ Address Same as Hauler <br /> q� N!A for I CERTIFY THAT UNDER PENALTY OP pZURY OF THE <br /> Q �t ( W OF THE STATE OF CAUFO 5 I THAT THE .. -. .. .. <br /> [..1i- NRtole Ti.) a o <br />