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Toll Fret 66-896-0600 / www.ciwmb. ovRires/ <br /> -- Califomia Integrated Wastes Management Board <br /> CA Comprehensive Trip Log and Receipts 10002 F1,Q,BDA 72511,9gcratnenta,CA 9li —1259 <br /> . 1� P e 2 Comprehensive TripNumber <br /> ""eia,�laro6�INSTRUCTIONS ON SACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE <br /> y algnlnp this CA COmpr■hw,•i,ro Trip Lop and Recelp6 the slprler(s)ro"t arm Un IMornw4an provlWd on this form la,R ti <br /> lie owaidered bonticII Proprietary and trade wont In addordalae with Tltla,14 CCA,8ec8on <br /> 17041 al sep.,If•r•quw Ie made far disclosure of this Information, r CIWMp will wntast the alener(s)of this lam at the address and twephorr number pr9o"d on this form or resedpt <br /> Hauler Address <br /> Business Name ���r��� <br /> 61 Address <br /> City, State and Zip �pJ .� �� �,A <br /> C Common L__V "`ZA <br /> — l/n <br /> Carrier <br /> I aaydfy und.r p■naly of Derluryundo'No lawn of Iha Bra of Calilmn{e Ihat the Inronna0on p evldad ebova is we R,W Correct.In addition,I am ewale 91011 at Inis in,oArultgn may result in auapenslon,ravoca4on,or denial o)ranewar or V,r <br /> Wear Tlra Hauler Repiatndon puraua0 Pub Rosourcos Code WAiOA 42960 and may result in dyll penalties up p;25,000 per day.00r riolafon a r ffa0re poruWaa up w;S,gOq j,,•r�iolNGon per day as dascl)tlad iA Ftc kasawcoa <br /> Cale sectbn 42962 / f G <br /> Driver's Name(print) Drly a Signature Date <br /> 347453 <br /> Hauler Tire Program ID / Site suffix Facility Telephone Number <br /> a � �-oro® aaoL� <br /> ,r �4;IIkl�+ �LdEoii'IGSfv <br /> ,� z ✓ ( 51 1G <br /> Hauler Name a L,Zi a <br /> �I4'1,iII 6 ;WAO-l� 'tamp or Label QK I <br /> Hauler Telephone Number Address Same as Hauler , ;gars <br /> I 1 GRRrrFY rR'T yNP/LR PBNALTY OF PERJURY OF THE <br /> 4X A LAWS OF THE STATE Oa eAL1FORNIA THAT THE C <br /> INFORMATION PROVIDED ABOVE la YRU V AND CORFIC <br /> • ■- a . • a III UPI <br /> n <br /> 3474538 reares B <br /> Hauler.Tire Program ID r Site Suffix ' Facility Telephone Number <br /> Ho -0oa -� a <br /> k F�oility F9iI J/AWdo <br /> 4 LJ aaa� Q I NarrleiAdaresu '1 <br /> Hauler game =its; �yial.fi'��ricl !il: ' d $ n! I�.t;'2 ..;�_ <br /> Stamp or label Crt� <br /> Hauler Telephone Number Address Same as Hauler <br /> I CERTIFY THAT UNDER PENALTY Of PO YHC <br /> uUTHAT T <br /> ss � CIY� <br /> LAWS OF THE STATE OF Ca1RNu THAT HE <br /> INFORMATION PRQv1PFQ ABOVE 1B TFIUF AND CORRECT. --`I <br /> • - - • / - ■ e a 1 e Y•Y e <br /> 3474538 __ A <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> u <br /> _ F-ac:iiity 0ue:,ine,;;iJVJ ,,-�; r. <br /> Hauler I Name �r ,�,{, (}� <br /> JIiioY"> hAl elr'�Cy,�c.. i,&E Starr)p or Label QK 06� e' <br /> Hauler Telephone Number 0,Address Same as Hauler <br /> ,. .y I CERTIFY THAT UNDER PENALTY Of PR'NduRY or THE <br />