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Toll Free%6-896-0600 / www.ciwmb.ftvfTires/ <br /> CA Com rehensivea Log and Receipts 10002 ,0.El <br /> Call1fornw 12551,SacreVated amete nto, <br /> C■EISS12 1259a <br /> _ P.�.90■nte9,Sacramento,an 984"2-1 oar <br /> Com rehensive Trl Number <br /> JC A AA P I L IE _ __,,��- <br /> �fisoiffaysl INSTRUCTIONS ON BACK OF PART 2 QQ NOT TAP S,TA OR DUPLICATE <br /> V AIpNng this CA Comprah—lw4 Trip log end R•ceipy dla signs,(.)r•qu••t tMt"latam fign provided On mis forth will be con•Id■,ed e—fidrnUal,proprhmry and trade watt,In•ewrd%nr,/with Thle,1 d CCH,'ut4tl Gil <br /> ,7041.,..q.,It.ray....,is.04.for d1weaare Pl chi.Inrormstion.the CIWM8 VAN,entad ttr aiffmr(•)•f VUa tam at the atitlr•w Ono 1a14phmw number provig•O on th4lorm,WMC4l L <br /> Hauler Address F�jl, <br /> Business Name VV <br /> O `I Address <br /> City, State and dip � � <br /> Common J� <br /> Carrier <br /> I Cerbry under penally of perjury undor Ma Iawa of,no State of Cailtentia Incl tho Intorno tion F6VIdQd above IF trua anti omit.In aodaion,I am away 11101 Niv fit y0s;Womwbon may r"ul Insuspension,rave on,or oar�l 01 renewal of v.: <br /> Wti52p TUB FWular RagNtrafjon purp0/IrA to P)ID(fs pwfiwws LoOa sac0oh Q.W 4JAd may result o 0A1 p• 14"up To 3 25.000 Wday,par VIOAtIon or ad �rst � fIkias up w$5,000 par violation por bey as tl. ralaa in Rublic Reaoumas <br /> Cad•aeedan <br /> 42962 <br /> Driver's Name print) Driver's gnetyre Date <br /> e •. MIME mull <br /> 3474536 -- C �=- <br /> Hauler Tire Program ID / Site Suffix ` O Facility Telephone Number <br /> F ciiii.y 13J1,'tiil9f.la: <br /> Hauler Name,f <br /> SIamp.or Label CCK <br /> Hauler Telephone Number Address Same as Hauler rrtarar <br /> I CERTVFY THAT uN06P PBNAt ry OF P■UURV OF THE <br /> LAWP OF THE STATE OF CAUfORMA YHAT YHw <br /> 1rOWMATION PROVIDED ABOVE Ig TRUE AND CORRECT, <br /> ■ • - • •• •. • • • ■ f <br /> 3474536 -- B <br /> Hauler Tire Program ID Site Suffix Facility Telephone Number <br /> Facimy <br /> / 1- c ' -2 'l 14 1 / Narne/Addrwss <br /> Hauler Name t%Ity, :>tste x�rlu a`..il+' <br /> {:�)r�7, oo> -��f> xti k-'L%�r.� "1t'F" i Ia S amp or L.abai OK <br /> Hauler Tpiephone Number III Address Same as Hauler ,a <br /> d. ICE FY THAT UNP611 P*NAI YV 00 PORJUMV OF YM15 <br /> STATL Of CAWFORMA THAT THE <br /> < UOVIM ABOVEUE AND CORRECT. <br /> 3474536 -- AJ <br /> Hauler Tire Program 1D / Site Suffix Facility Telephone Number/ � <.. 0 � , <br /> m <br /> tHaulcir <br /> i.Aj Name C(Y, :yiake i.s W 4.li4UJLWa, L'11 S amp or Label Oh <br /> Hauler Telephone Numblir Address Same as Hauler ,nrUal• <br /> %! i 9•'i r T�r • - 1 CVMFY THAT UHO•H P■NALYY OP P•RJURY OF INS n <br />