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Toll Free%k6-896-0600 / www.ciwmb.Mv/71res/ <br /> Ca1lfcmlaInt•grale4 Waste Management Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Gacramanto,CA 0581:-1258 <br /> E'X R3M P 1 2' 3 - _- Com rehensive Tri Number <br /> "vePosflaosl INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE <br /> y ryn ny r1W.CA 0—pr-1—Trip Ley and R/s.IFd.uy serer(l)repueat that rt.hll- ti-1 jx—ldad-IN.farm C ly be COna1M",Iad...Ild0nhal,PrOPrhpry arnd V•d0•i,c.t.In ll-0-0 witty ril e.14 CCR.6Wcliou <br /> .7611 at aap.,It a &Q-1 1.—d.for g10dOsurO o1 Ih10 lnfamuycn.the CIWtia will contact the stgner(s)91 thl►form tl tt-add'au and teteptiono numDOr p—=on Inla loan-gc01pL <br /> Hauler Address <br /> Business Name <br /> 4. Address <br /> City, State and Zip r 146x <br /> [t -I Common �17�� <br /> C•--� Carrier <br /> r/.0 Jfy YOOef pena,ry or DOffury undefIL law:o/ILW Sta;O e1 CallturtJe InW l AW,ii ilurrrudi00 Pmvinatl ytx,va iG"a•nd caroti.In addl0on.I aM awarW v"" 09P10(INAYdkRnaDJh may rasYll In aYaparSi4n,rWvOdapYll,d/JW11dt Ot renewal JI j,,,tiVaste Tire Hauler Re�stratlen purcu nt_M puDlj�R Gowws God fi,"60n 4�W mid may reeull in civil perWlYes up to S 26,000 per day,per vkdo.oe W 'Ga penaulas up to 56,000 Per vlduLan par a:y ac tlaaaiwJ✓,pyb4c Reswrea. <br /> Cade t:ectlon 52962 /L9l <br /> Driver's Name(print) ignature Date <br /> • - . . •• - <br /> 3474540 -- C <br /> Hauler Tire Program Ip / Site Suffix t Facility Telephone Number <br /> ral)ae17�ltlittJr . <br /> Hauler Name City: Airtilo d0o .=.11, <br /> Stamp or Lgnel OK <br /> Hauler Telephone Number L_.l Address Same as Hauler , <br /> I CERT1F1f THAT UNDER PENALTY OF PERJURY OF THE <br /> �.SIl , ,(�;F• � � '�'�1 i� <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> (( V ! ^040 CORWIG <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> ,,: f=rxCiilty �3li�iidet�ci �f'�';�J' �,:(•i r!1rL r�,i� <br /> Nitst'tEljAdiYil.MS /l <br /> Hauler Name <br /> Stamp or Label OK <br /> Hauler Telephone Number E] Address Same as Hauler <br /> ,• r I CERTIFY THAT UNDER PENALTY Or Pup"ROp TN• <br /> LAW$Of THE STATE OF CALIFORNIA THAT THE <br /> N NPOAYATION PROVIDED ABOVE IB TRUE AND CORRECT. <br /> 347454 -- /4U 0 E 0 @ 0-071 <br /> Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix /? / 4 <br /> I a -� a <br /> ��ilitala e.;_.ir'a.`.._ 'h,.���.. ri: (f� , ,:f:'.�Ir• <br /> ss dii11'141e1tig1l tat'>: 4 <br /> Hauler Name <br /> t�l <br /> stamp or 1-413&1 (..IIs <br /> Hauler Telephone Number D Address Same as Hauler D•la <br /> 'Ail. i �, s , r -"7'9 �. I C5RT;Fv T„C R-11 <br /> '1 WM LNA cYYD P PO4JURY of THC I. <br />