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Toll Fre%66-896-0600/ www.ciwmb.ov/Tires/ <br /> CA Comprehensive T CaiO.Boxernis 269, acresiltil ento,Clilte 9.5812 12S9Boarq <br /> Trip Log and ceipts 1 U002 P.O.Box 1268,Sacramento,CA 95812—12fi9 <br /> E M P ti Corn rehQnstVe Tri Number <br /> ieaoinwEj <br /> I....w ` INSTRUCTIONS ON BACK OF PART 2 DO NOT T PE STAPLE OR DUPLICAT <br /> V atdnlnp thla CA Comprehensive THP Lop and Reooipt the alpiwr(A)raga..'that the Inlwmagatr prmlded on la form will Ds oonaWared oonlldentiat,timpAatarV and brittle aaonL In aecordanoo With TRW,14 CCR,Ssc0on <br /> 17041 et sea.,H a raau.Ai la m.d.fpr 41sctware.l this Information.brie CIWMB-rill w,tart tfW aipn.rls)m this rm r UW addises and Wepmw nu{m� pmwkWo rm Ihl•rpm er ramp$, <br /> Hauler Address <br /> Business Narne �U <br /> Address <br /> J 1 City, State arid Zip <br /> ornrrlon L �C-C, �/ �✓� <br /> -•• artier � ._ . .. <br /> t codify und.r penalty of perjury undaf Na Iara of ala 8mfa of C991aNa that the Info pradaad aoova la trues a.4 c t,In aoclWon,I.n.Ware Ir EaI S.tion W InW inionnawn-4y rn4it in aasponslon.ravocatmi,a aanla of relhlwA]of In, <br /> W..to T,r.Haul.RspiatraWn pytuant to PI`IiRaaourcaa Coda Dation 42NO and ay result N cNN ponaWaa up ty y 4,O00 p•r Wy.PEI viululiu.� �Vnuvo parlalEur uy w 86,000 y.r.wx.ti.n ryr pay as oesc{l",I m P„onc Hesourcax <br /> Cera•aAemn 490da ) I : I <br /> � Ir .rIhl c ✓� � J <br /> w <br /> Driver's Name(print) Dri is Signature Date <br /> a .a .- •. • • • . • • <br /> 34 ., 453 - C <br /> Hauler Tire Program ID / Site Suffix f Facility Telephone Number <br /> i°i.eliity Bl.itsiiies". <br /> r,'✓ ,,. �� �„ '! 5 41 NattiWAticl.•�e. <br /> Hauler Name Citv. :dt€m!%tqo AiJw <br /> f r* 5; G%:e�G "i,JZ�z Stamp or Label CM( <br /> Hauler Telephone Number � .� Address same as Hauler �„� <br /> I CERTIFY THAT UNDER PENALTY OF PERJURYOF THk <br /> rK f�I y� r)J. '• J ` 1.3 LAWa OF:Ytra STATE OF CAWFQRNIA THAT THE <br /> I FO N PROVIDED ABOVE IS TRUE AND CO T, <br /> • • • • • - e a • • ' <br /> Timm <br /> 3474535 B :' aa ;: 0_00 <br /> Hauler Tire Program ID i Site Suffix Facility Telephone Number <br /> Fraai111.y t3iJsirtrss l)�, /�: �f�,, IC'% <br /> Hauler Name kty.. :>fi'.StEe alla flk <br /> Starstp or Label CCK <br /> Hauler Telephone Number [] Address Same as Hauler suets <br /> '1 7.z 1 CERTIFY THAT UNDER YENAI.TY Pa PBf�JURY OF THE <br /> '.t/1� _ "�' ��(' LAWS OF THE STATE OF CALIFOR14A THAT TnE <br /> IN 01101 F140YIPRP ABOVE IS TRUE AND CORRECT. <br /> a <br /> 3474535 _E. ,n, <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> Qa <br /> c'� � fi- aal� >1 1 i'F4i.:ilRly" i:�iA•al<1E;.,;��f -�� yry, >�� ':�", k�'��, <br /> Hauler Name E.Siy .nl:ik! ;iP,'C .:.�lj �`•�Jf y!7,;� 4 '�; <br /> Jtn�%Gp�`rwdrs" (�C.hfi►+'F��ist�. ���= ;�tar►�p ear t.ai;;ei t)tC - <br /> Hauler Telephone Number Address Same as Hauler IH;rja <br /> .., , Y 1-;...y A.y I CERTIFY THAT UNnf(q P•NAL1Y OF PERJURV OF THE <br />