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Toll Free . J-896-0600 / www.ciwmb. _/Tires/ <br /> - CA Comprehensive Tri Log and Receipts 10002 CaliforniaP.O. aIntegrated2.91,Sawitate nio,C 895812 t Utldrd <br /> Trip P.O.Box 1269,Sacramento.CA y6h1 L -12':D <br /> E Ix A All P I L E 1L2 f--� � Comprehensive Trip Number <br /> ! 4 3 J <br /> INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAP R DUPLICATE +r <br /> 9109 <br /> mW(1tYthl <br /> •ignfr.y CA Compr.hw,Wr.Trip Loo rnd Receyt4 the alflner(cl r•gtre■[that the hNw mauan proNd•d on this roan will G con•id•r.d conlid•nilai,Proprietary and Ir■o•s•=n,,(r,,==.rd..r=.w171r,TRW,14 CCR 9.=uun <br /> 7—.r..a..n.rr—t I.—i.for dila—un d thte Itgannetlon,th.CIWUB will cnm.ct it a etgnerya)of thfa fotm et the adamss and t•lgpharw n.mloar providdril on this form or rt 1pt. <br /> Hauler Address <br /> Business Name /�!h►�N u/ u�%y /��s� f' <br /> Address 6 <br /> City, State and zip <br /> common <br /> �- -� Carrier <br /> 1 Ceryfy urwer piul y of pe/wry under the lawn of pW Swi4 of"ilforr.I:that me irlformbbon proViot4&DO,6 is true W4 OOyr6rY.10 04aIWn,I■n)aware tvt rqw �n of n6 wVm,vhon may rowR m suspanslon,i evocAuan,of damn of ranevfai of m< <br /> Waala Tiro f1etl+ar Replatretion puraua��d PubllryR•n wrote Cf.-O6 6aCaoft 42960 and may reauit In Cita+peflailt"up to S 25.000 0&day.per vlolauon �d bV•OYa pene+aae up W SS,t104 per viWa4a,Per day as des,�ltpo Vr PyD�f;Reeow[as <br /> Cade eeaon 42962 <br /> 7�� ✓moi''f F'/J — - -- <br /> Driver's Name(print) Dri 'r'a signature Data <br /> 17 <br /> 3474541 --, - OHEPROO- <br /> Hauler Tire Program ID / Site Suffix ,y Facility Telephone Number , <br /> Hagler Name <br /> Stamp or Label 0K <br /> Hauler Telephone Number Address Same as Hauler <br /> ' I CERTIFY THAT UNDER PENALTY OF PERJURY Qa YME <br /> ,./)'�� t f//,? / '9'!r(� LAW6 OF TH9 5YAT•OF CAWORNIA YNAT YHe <br /> t' 7tttrORUATiON PROVIDED ABOVE IB' RUE T. <br /> CORREC <br /> t <br /> 3i, <br /> 474541 -- B <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> OrOD DOD DDD <br /> r <br /> !ruCITY;ilriy <br /> Hauler Name ;�+/`}) �; <br /> Stamp or Labral OK <br /> Hauler.Telephone Number D Address S"01IN <br /> Hla <br /> I CERTIFY THAT UNDER 5 ^� <br /> LA.WB OF THE STATE OF THAT G,1/ <br /> N/FORUA PRO i t <br /> 347454 . <br /> Number <br /> ty Telephone <br /> Fac <br /> Hauler Tire Program ID / Site Suffix Facility Nmr <br /> HOH-Hm'm � DOE" <br /> r i <br /> rl E r 1 t <br /> Hauler Name <br /> Starrip'cr Label OK <br /> Hauler Telephone Number - Address Same as Hauler r„rf„r <br /> I crtnT7fY THAT UNDER PENALTY OF PERJURY OF THE <br /> t,.. 1 <br />