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Toll Free 66-896-0600 / www.ciwmb.,.. .gov/Tires/ <br /> California Inuar■tsd Wast■Management Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA9s812-1259 <br /> Com rehensive Tri Number <br /> INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE <br /> 3Y"Ig-9 lhre GA Comprenenslw Tdp Loy—d rl—lpt,u-signer(fl)repuear N.1 ch.rrAom-uon Pvvlped on this total-.411 De oonslWrad coMldeniW,propMtary and U.d. h," wd■nC"with TAW,14 CCR, <br /> 17"1 et asp.,If a requost Is m"d•1-dle.losare of this Int,,maeon,ma CIWUB rill carload IM sl•nwis)of bila form at the addfrs and bQlepfrota num[wlr,Providad OR this <br /> to/ws/ar/ Jppr. <br /> Hauler Address <br /> Business Name I f�lJl�/v T /N �/'T"�7 L-7" S� <br /> Q Address /-� 0 <br /> City, State and Zip J'U �/ <br /> I t� -4 o � <br /> Carrier mmon <br /> CeIVY under penalty or Wury,.oder the law&U the Stata M CaMmiA[hat the Intortna0on provided abw a is vue eno corram In Miller.I am aware on of ails wormatlon may rmwl m fu.perteiun.rovocatro ,or oaru8l of ror1aN4I pl the <br /> Waste Tire hauler Reostrau. ggq���qua�r typutNic Resources Code%aeflon 42980 and may result in clwl perulWr up to f 25.000 per day.per viaauan ketiw Penalties up to Sa,000 pat Wolsrion par dyy a■tlesc In qulrlic HesowCas <br /> CoOe <br /> motion 4296E � �") I <br /> Driver's Name print Drivor's Signature Date <br /> ■ 6 - .. •• .. ■ • • • e <br /> 3474534 <br /> Hauler Tire Program ID / Site Suffix 1 ; �� Facility Telephone Number <br /> a 0 E H R H 0 0 H 0 <br /> `r! ( /'� (�' r+ d:•) / Nacrte/rAddrE!;is <br /> Hauler Name City. staw alzd 1'ip <br /> Stamp or.Label OK <br /> F auier Telephone Number Address Same as Hauler -1 <br /> >u�i �`�9' / I CHIYIPY TIIAT UNDER PENALTY OF PgA.IultY OF THE <br /> �1 / J t LAWS OF ThW$TATs!OF CALIFORNIA THAT Till! <br /> INFORMATION►RO TRUE ANO COR T, <br /> • . ■ a• a- ■.• • ■ a • <br /> 3474534 -- B r c > — <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> o t� a-ooa <br /> o <br /> �) � ,�: -'lam q' [� p I'�Br..11itjr Ctl.fflilP'^'s + �d.', j7,�1 �/,J�,/.-,��-1!�ir r�,r'•!,.:� <br /> r„� r � f 1 111i#tYi�ki�lltit�r?»:iW f� J <br /> Hauler Naity, Sidit!.4f'o.41V)i � x f f�` <br /> Name «; <br /> �tll,'hFn.6! fil lddil�Gs ”//,fi r' Stamp qir i..atsai OK <br /> Hauler Telephone Number ` [] Address Same aS Hauler In;tral <br /> CERTIFY Y"AT UNDER PENALTY Of PERJURT Oe YHE <br /> �G-'1•��( J "' 1 !r C? LAWB OF THE STATI0 OF CALIFORNra YNAT THE <br /> INFORMAVION PROVIDED ABOv UE Aw0 CC ECT. <br /> ■ e a •• • - ■.■ • a ee i <br /> 375 -- A <br /> Hauler Tire Program.Ip / Site Suffix Facility Telephone Number <br /> r � <br /> . o a®- as <br /> roan;�r>til�;iiaik,� `J�d _ <br /> Harder farms <br /> q-5 i <br /> wtarrip 6r a ibal K <br /> Hauler Telephone Number �� f] Address Same as Hauler <br />