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Callfomia Integrated Waste Managamant Board <br /> CA Comprehensive <br /> Er< zs 3249686prehensive Trip Log and Receipts 10002 Boa 1259,Sactnm-to,CA 95617-1359 <br /> Com rehensive Trip <br /> ri Number <br /> � <br /> l�wus=(t ws)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE <br /> BY"anlna Mil CA Ca pfth.n.N.Tr1P Lae and RswlK Ma alawrl.I nous"that the Inlo-10-W-I6t,d on W.farm w H W 1-1dsr.d oo,,d.ndal,Propl.lary and Ind.—L In accuWncs wIM P W,14 CCR,fsollon <br /> 1 70s N Iso.,n•rsow"la,ud.for 11-1 sun of this I,famaUon,M.CIWNe will eoMa<t Na apwe(sl of NI.form"MI IdOnss and IlHphons numtNN porMsd on Ml.loam or raeslp. II <br /> Vehicle Information <br /> Truck Decal Number Hauler Address �,�,�, Y'Gf h G f� 11, <br /> Business Name �a PG <br /> © — a Address 0 . 13o,r yo 7cu <br /> License Plate Number <br /> State City,state and zip <br /> 0 o a ® a© a a® Carrier, J <br /> 1—'Y.".P.nelty d Penury—Ne I—of the SNn d Cardamla Net Oro IM row"..poNOad above N Wa ab mrtect 41 addWan.I em swan Net lahif Um of Nro NllonnaUan may result N suspmabn,nvoolbn,d denial of,newel dl M <br /> W.-Tba�ubr R.go.uon puna.Io Public k—Coda aac IMO arH may—1 N dil Penal.w b E 75,000 pr day,Par rlo~or admimslnUre Penaw-,o to 55.000 Par vldaUon Par day as daso,bed M P,tlUc Raea— <br /> Cods.1 <br /> 1 <br /> aLVr`G' 0910S072048 <br /> Driver's Name print "Driver's Signature Date <br /> Comprehensive Trip Log .. Tire Program ID Site Suffix <br /> d Information.3 2 4 9 6 8 6 -- C Number Pick Up Delivery <br /> o as <br /> .� D 0 0 0 0—0 U <br /> a Hauler Tire Pro ram ID %`.Site Suffix DATE Facility Telephone Numberg <br /> tC9 Iuac®Whole Tire Count Weight In Lbs. ®®©a a <br /> r—Flity�sinf�) <br /> a`J � <br /> 1610 3j-131 � t7 1 �E] VolumeCubic Yds.�Weight in Tons N e/ dres <br /> $ (Per Name aA' <br /> L) <br /> Hauler Telephone Number ■�® ❑.AddressSameasHauler Initial J <br /> IN IA for I CERTIFY T UNDER PENALTY OF PERJURY OF THE <br /> Wa <br /> v , �tl� NRlola Tlroa( UOF THEE Al1 <br /> STATE OF CFORMLI TEAT ME <br /> INFORMATION PROVIDED ABOVE If TRUE AND CORRCCT. i <br /> Comprehensive aLog Number <br /> 3249686 - B Pick Up 0 Delivery o �, <br /> Hauler Tire Program ID / Site SuffixDATE 3 / Facility Telephone Number <br /> as <br /> oo a© _ S <br /> Cw•[fl Whole Tire Count Weight in Lbs. <br /> MA <br /> / �� FNaffil�/ A <br /> Volume Cubic Yds.O Weight in Tone e s <br /> E Hauler Name/ `Cr /awe <br /> Stampov0at)6ifQ. <br /> Hauler Telephone Number' ■ Address Same as Hauler. ,,,fiat, <br /> (N IA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> WlaOle Tire.) 1-A.3 OF WE STATE OF CALIFORNIA THAT THE � . <br /> INFORMATION PROVNEO AR.-IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program 10 Site Suffix <br /> 3249686 -- /4 Pick Up a Delivery <br /> Hauler Tire Program ID / Site Suffix DATE Facility Telephone Number <br /> . . ®© � �m w. Whole Tire Count Weight In Lbs. OEM <br /> ®®©a <br /> a= rF/�J tt�B��}jSi 5 <br /> a 91, �. O Volume Cubic Yds.0 Weight in Tons Plrff��idre s <br /> E <br /> Hauler Name Gtyt d�Pip71 v 1/y R� <br /> w <br /> CJ 0 1- /✓'7 �' Stam <br /> < P <br /> Hauler <br /> Hauler Telephone Number E. <br /> /� <br /> Initials <br /> ,/'� C� (H/A IOr I CERTIFY TAT UNDER PENALTY OF PERJURY OF THE WhOla Tires) uW8 OF THE SPATE OF THAT THE <br /> INFORMATION FRONDED ABOVE A90VE 0 A TRUE <br /> RUE ANO COR0.ECi. <br />