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Toll Free 6-896-0600 / www.ciwmbec._ v/Tires/ <br /> ement Haar(I <br /> CA Comprehensive Tri Log and Receipts G.O.Bo Integrated1250, Wento,asize A95612-1269 <br /> �I QQQ2 P.O.Box 1258,Sacramento,CA 95812-1269 <br /> E_X A0i P 4 E 1 2 9 w Com rehensive Tri Number <br /> INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE <br /> 7.Pn ria Ulla CA Compnahonalva Trip Lap and Receipt,the siDner(al raquasi Inat"Inionnallon provided on two lone will be consWerod conlidentw,proprietary and trails seat.In accc.d..w whn t1 CCA,7041 et seq.,II a request le made for dleelosure of this inrcrmsren,the COWNe will.ontaat the slynenv)of this form at N•address ane WaPNun number Provided vn dila larm.rracal L <br /> Mauler Address /Pd_ /I A-` JBusiness Name �I"1 , /"AddressCity, State and ZipCommonCarrierBandy vnoar parmlty ut Pw,jw.y vn• ,via:a«:of tna stat.or Cadtumla that utamlorrnaaan provided above 4 wa and corrocl.In.0.1lon.i am ew< r t Ylcauon of Ina'Intortnatlon may reaWt 4+evapeneim,nvoeai%a�denial dt rbney;u of u.. <br /> aria Tire Hauler Registration pur7- <br /> Till., <br /> Pubiic RtiiLOOlEaa Coda sernon 42%0 and max("Wit In Gvil Penalli"„p in a 25,000 par day,par wa o min trarIve Panalt)ea up to 15,000 per violation per day ata deem d M P lic Rcso.rca4 <br /> Cow,aaman 42962 <br /> Driver's Name(print) Driver's Signature date <br /> - - 3 11'.11 1 111111M 9 •. • . • ■ <br /> Hauler Tire Program ID / Site Suffix ,� Facility Telephone Number <br /> aoo <br /> l Facility E3u::>ine� >. <br /> Hauler Name t�ity, tatL zkrlCt ac.Ild <br /> Stamp or i.abdi OK <br /> Hauler Telephone Number [] Address Same as Hauler J <br /> I CERTIFY THAT UNDER PENALTY Oft PiigJUnV 06 THE <br /> 104 - <br /> n(�z/ �/'J2 / -% ,,I LAWS OP Trye STATE OF CAL)PORWA THAT THE <br /> /'( INFORYA M. VIDEO A9QVF 19 TRIM AND MA99CY. <br /> 3474539 -_ B ,x' / E i 110 E-E I <br /> Hauler <br /> Tire Program ID / Site Sutflx ej <br /> Facility Telephone Number <br /> ` Facility <br /> ILL — <br /> I/ Name-/Address <br /> Hauler Name <br /> City; :tiat4 and Z.it,• t' <br /> Stamp or Label OK <br /> Hauler Telephone Number / El Address Same as Hauler Initials <br /> 1 , I CWYVV THAT UNDER PENALTY OF P6RJyRV CC Yn• <br /> LAWS OF Thai 61ATe ON CALIFORNIA THAT THE <br /> G• 'r�rI�- 01RaIATION PROVIDED ABOVE 15 TflUt AND CORRECT. <br /> 3474538 -- A <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> 000 �� oa � oQ <br /> FH—avle,-Telephone <br /> auler Nama <br /> lit- <br /> Stamp or Libel OK <br /> Number- Address Same aTY Or s Hauler <br /> THATFlUNDER 6.6Ha�rnwwa TWAT rHF THE .. <br />