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Toll Free%i6-896-0600/ www.clwmb.L )v/Tires/ <br /> CaMom1EIntegrat•a Wa/a Management Board <br /> CA Comprehensive Tri Log and Receipts 10002 P.O.00K 1259,6acrarn•nto,CA 45614-1259 <br /> �.y M P 2 3 Comprehensive Trl Number <br /> ai r<r <br /> -`a1ail INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAP OR DUPLICATEMM <br /> I signing thla CA Comprehensive Tnp Lop and Receipt,the algner(a)request trot tllo IntdllnaUOn provided on this login will be oonallWed co..Ad.ndel• intorldtary and trade•moral.In accordance with Title,14 CCR,Settlor, <br /> 7041 at eeq.,d a request Is made toe diselosure of this Inlormalion,the CIWYB will Conlaim the slpn•r(s)of this lone el It.a addraas and telephone nurnber fwovldad on Milia/form or taoelpl. <br /> Hauler Address <br /> Business dame ' <br /> Q Address <br /> City, State and Zip f <br /> C � <br /> ommon � ' 9�338 <br /> arner <br /> oe6fy under penalty of perjury under Ina laws of the State of Calltomla that the Informatl provided above is true and cortacI.In addition,I am aware Ina;RI o is Information mey raevlt In seeparlalM,ro+ ti' 41 denial of redawal of u,. <br /> sale Tira Hadar Ragi.valiao p-wA! pvUliC motes Code seovon 42960 9ne+*6 y r9evh in N.il pananwa up to 4]5,000 par day.per vlolation orad n' r P4AAIU&a up to 55,000 par vM"W par daY ar d scrloatl Irt,Pudllc Raaourcoo <br /> Coda oeation 42962 �/• <br /> Driver's Name(print Driver' ignature Date <br /> —171 r- <br /> 3474531 C � - <br /> r <br /> Hauier Tire Program ID / Site Suffix t Facility Telephone Number <br /> ROE-BRaoaoo <br /> 7 n f 1=t��iliTy !3►,jt,;irtr�;'�* <br /> Iia ler Marna 1, IOtV J <br /> /i✓�iY;roat Stamp or Label OK <br /> H <br /> Address Same as Hauler <br /> Hauler Telephone Number <br /> 1 CERTIFY THAT UNDER PENALTY OF PERJURY Of YHE <br /> LAWS OF THE STATE OF CALIPORNIA YNAT THE <br /> ( rawY;ON PROM 0ASOVE IB TRUE AND CDR ECT. <br /> 3474537 -- B <br /> Hauler Tire Program ID: / Site Suffix A Facility Telephone Number <br /> U fl <br /> HOO-HuaooQa <br /> `/ �) � •� � ! ,�T � � d iVr�t�iE=lAcfdr�a�;t;; ��;/b�,�rl; �f� <br /> Hauler Name <br /> /� I:ity; �Ita►e �l)1;3 L.1�' �/e/�f� <br /> r' , 'D/ (.'d,�il �✓�L- /Ii?�" Stamp or Label OK <br /> 'Hauler Telephone Number f D Address Same as Hauler <br /> fn tr fa <br /> ,�y I CERTIFY THAT UNOEa VENALTV OF PERJURY OF THE _ <br /> N,.{a'7[jJ/] A % �j/la I,AlY3 OP THE$'ATE OF CALIFORNIA THAT THE <br /> l/ I^ / INFO N P 0WOED ABOVE IS TRUE AND CORRECT C <br /> 111"G WOMB P1111 <br /> Is A <br /> 3474537 -- A <br /> hauler Tire Program ID / Site Suffix I Facility Telephone Number <br /> E 0a-arja © aoa <br /> �r 0 0 P JI ,111 t") t11i11'1'ir''/)li�C31'Ll;ii> If <br /> Hauler Name 1 tl�ir :9T t9k.E!rtfla't I, <br /> Ai "aIA1"(h i� irs �J Stainip or Label OK <br /> Hauler Telephone Nun7ber 0 Address Same as Hauler )R ad <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF <br />