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Toll Fre.. X66-896-0600 / www.ciwmbfov/Tires/ <br /> Calltornis Integrated Waste Management Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.'Box 1259,Sacramento,CA96812•.T259 <br /> Com rehensive Tri Number <br /> "'�ezosjfro57INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE QR� T <br /> signing thia CA Compf9A9n.iy.Yrip Lop and Recelpt,the slgnarpl eq ioel Mat the pdormation provided m nd.{arm will be conolOwed cardldanllal,proprietary and undo a.aret.In e000idsncs with Till.,14 CCR,Illicit.,) <br /> 641.t ang.,it a re itrost Is mod,im dl.daaure ai thl•tnlormaaon,the CIWUN will cOnul;t the slarlsr(sl 01 11119 lora,.t tM oddr and rl.phons aiwer r pmwWay an this loan or reoaipL <br /> Hauler Address ,J,,��` / VP <br /> „_u 1qZ::SSrBusiness Name � //V c�l (�!� ' <br /> � j 9 -` Address � t <br /> City, State and Zip �� b 6 <br /> 1.-•� Common �...!i niv�C '� <br /> Carrier _...� <br /> I certMy unser W+nalty of oariu:y uneer the laws of the State of Calltomi.Met the Intomladon providad above i9 aa9 snd wrreC1.In addition,I am aware that I? %gih of Ihi.inlomlation may r9pull m a4epansion.revocation,m d.n,al of r9o4w4i of Ldf <br /> Waao rlro Haulor Regietrabort purauf1jo Fuh1&5tAx UrCBS GOde 86F;UCn 42XC ar,d mgi r68C11 It)Civil p6n811ies Lip to 3 25.M par day,per violadon pr gdmi five paruWsa uji m 35,000 06(viOlation per day as dsa ibsO nl i''uhMc Raiz.,ee <br /> God.a.coon 42962 J <br /> F i°y <br /> Driver's Name(print) Driv s Signature Date <br /> 3474542 <br /> Hauler Tire Program ID / SiteSuffix / Facility Telephone Number <br /> HO �� r/, E <br /> / r iciii}y51 <br /> l�J f l ! I#kl tivr't�(�C1X'C3i: <br /> Hauler Name City 'i,ttite;r'ar;- °ill <br /> Hr!��Or.>�" ,A�,c-�t•lri«�,�. !/E'f� Stlic'Itp�r l..i?at,t�?SPC. <br /> Hauler Telephone Number Address Same as Hauler I ilia, <br /> I CERTIFY THAT UNDER PCNALYY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFtMNLA YHAY THE <br /> Wf AMA ABOVE 18 TRUE AH CT. <br /> 34745'42 US E 0 0 f, :}' -0 0 <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> N PUB <br /> J t-" <br /> a. �) t�163t1}t�111(t117t3C;;.. F`i J <br /> Hauler Name city, stiiltle ialtiI *lip �! <br /> c--. 7 Starrlp or(~nt,R#i 4Jk' <br /> Hauler Telephone Number � � Ej Address Same as Hauler <br /> I In,N <br /> /7 <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF YMC <br /> LAWS Of THE Il OF CALIFORNIA TWAT THE i t <br /> MAWN PROVIDED 16 TRUE AND CORRE07. l" <br /> •' • • a• • • . • a . ► • i <br /> 3474542 -- A V <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> � o <br /> G' l i' et.IfiCt <br /> _ o r�- <br /> y <br /> Hauler fl(aine <br /> �� 1'te fnl3 or Labeii , lR <br /> Hauler Telephone Number E] Address Same as Hauler Ila,_ <br />