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Toll Free 366-896-0600 / www.ciwmb. ovlTires/ <br /> California Integrated Waste Man•peafant Board <br /> CA Comprehensive Tri Log and Receipts 10032 P.O.Box 1y59,Sacramento,CA95812-1259 <br /> IL <br /> aria- ERX +� MJIPL C Z P 3 = Com rehensive Trip Number <br /> vaioitl o"a�INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUP ICATE <br /> !V■!lining this CA Campr.h•nsl a Trip Log and Rac•lpl,the aignerlal raa—t that this Inlo .U—W—id■d on flu.f.:. Ul 6,ron■leared oontldentlal.Oro ry will tratl•■■arat.In—rda—with TW e.14 CCR,$.Minn, <br /> 17041 Of sea..It a r•auasT I.A,.d.la el.dwum al tlr.IAPr.u4.n,fn•CIWNIR will...t—If.algnarf■)of ell.(.1..1 u..add—ane fli.0 nit number Ided on thlo loan W M C*WL <br /> Hauler Address <br /> Business <br /> Business Namo <br /> D Address /loV b/ q <br /> City, State and Zip t/ <br /> Common <br /> Carrier <br /> certry under penel:y 710eriurr„ne.,e..i.w,nr u..SLI.or c..:w.,,ia that rl,e Inbrtnaoon prm-lasa ace.a is IN..ro ear,•d,In aadaioo,I.rr,a.rr.u y91■su' of u, ntturm.uon may—t III w•p•n•ron.»vocegon.Or dams!el renews:vl Ir: <br /> Wa rTke bWon ReglstrslWn pau�ry <br /> urW pU-b-W '�wa C+attl auction a2a50 aha rtlay rsWt h avn porunl•s�P to$25•UUu p•rsa <br /> 4y,par vmuuon d b eUve pa nan:.s u0 io L6,000 par vioution par say•.W cubed In PdDLe Haeoureec <br /> lt <br /> Driver's Name rlpt _ Drive7s 5ignat re � Date <br /> • • 4 wry, � • .. r^- •• a • • • .■ � <br /> 4 . <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> 1 ! / J ; F cliity BijslofftiS <br /> �,� tri me/.Addres,, <br /> Haular Name ' <br /> City. State alld:dip <br /> S arnp or Label OK <br /> Hauler Telephone Number `_I Address same as Hauler Initials <br /> I ca rrWv YIUT flalpaR PMALTY OF PERJURY OF THE <br /> LAVI a OF THE STATE OF CAUVOMMIA MAt TRC <br /> IMPAND CORRECT. <br /> • • - -n •• •- • • • C / .� • • <br /> 3474533 <br /> / Fat:lllty T <br /> Hauler Tire Program ID / Site Suffix aelephone Number <br /> -�a�a�o � aoa <br /> Facility <br /> Hauler Name ("Ity; State:ar;:: <br /> S arn_ Por Label Uk - <br /> Hauler Telephones Number Ej Address Same as Hauler LrjAWs <br /> 1 C TIFV THAT UNDER P•NAI-YV oa PaRJURY OF THE <br /> LA OF THE STATE OF CALIFORNIA THATit t1', <br /> iNF ATION PROVItk.'O AaOVCORRECT, <br /> J T� �� art. �• <br /> Hauler The Program 1D / Site Suffix Fs ility Telephone Number <br /> F' Cil#t 9Y�tt i�la?:� �y(ji <br /> - ♦ < <br /> L^, J 3Vtlltle.lAsltfrputs �I�l/ ?i LZ/� <br /> H eu3Lar Name �:iV, `.:,tate.;r;L�:''i}I�,� `�i.✓� rl�k'.%r;r"rr t��• <br /> i'.�l�t •-T S�amv ar'Labal UK <br /> r- I ! 1. Address Same a� Hauler J <br /> Hauler Telephosye Number tR I <br /> n C . 1 c rlPv YKAT kJ%MR PENALTY of PERJURY or YHr <br />