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*'� eomla Integrated Waste Management Board <br /> CA Comprehensive Trip Log and.ftCl <br /> keipts 0002. P.OH.eos1259,saD.amento,CA 95812-1259 <br /> 'eel: AMPL E1 23 Com rehensive Tri Number <br /> -:;;... EX � �- <br /> aiws"m3("(1045)INSTRUCTIONS ON.BACK OF PART 2 DO NOT TAPE;STAPLE OR DUPLICATE 3,5 2 O.2 81 <br /> BY W9.Ing NN CA Cenpr.I W.Trip Log•nd R—IpL nr•gn•r1•,r.A—wt Ow Inbnn•Oan prwlaM m alb Imm WD D•-romla.r.d conlWpN•1,propd•Nry•nd nae•••el•L In•ccera•m.was TIM,14 CCR,3•dm <br /> 17001•1••p.n•npu•at N mtl•ror m•c1o•un a 0"4Awm•em,"CIWNB wu mntacl lM•grMq a Inl•bras•I IM.EarpF a bl•pMn•nasi—p—kh d!on Uft I—or I c.(P. <br /> e c e11fild-ft-ation Hauler Address �I� ��®� TIRE <br /> Decal Number Business Name 1"A <br /> Address 3730 N..WILSON WAY <br /> License Plate Number State City,State and Zip - <br /> STO,CKTON,.CA 95205 <br /> U o:®® © ® ®. 11® CCom <br /> arrie on <br /> f o•rtity un0v un•eY o/pOvjury une.iM Nva al w Sr•N d GGbrN•NN uw Sd•rnnlI,,p,11.d mor•N tr-and pones.In•dd •vn Bel NAW-don of W.kft—on mry r—AI in ar•W.I-r•ra d—or d•nle1 of rs 1 of eN <br /> Wnt•nn F7•uMr R•gWndm Wr Nud <br /> .90 <br /> Pk R­Cod•••tlbr142NO•n0 mry..Wt FA U P-114•"DID <br /> r 2"", <br /> 5.000 D•r .D•r •tlgn Or emniNsbWro perWOM,�b 13,000 per Ndenm pr d•Y u 6-66 N PIAge R•sowcp <br /> Cods•anion <br /> - 704 31 <br /> Drivers Name rmt) river's Signature Date <br /> Comprehensive Trip Log Number ..d Information Facility Tire Program ID Site Suffix <br /> 352028i�._...0 'Pick 11.10, ❑ Delivery 1111 a a 110 0-0 0 <br /> Hauler Tire Program ID;7,Site Suffix Facility Telephone Number <br /> DATE <br /> a'[:]:Whole Tire Count Welght in Lbs. <br /> 1 0 01 9 9 4 01 IL Facility Business <br /> `u E] Volume Cubic Yds.[]Welght in Tons Name/Address <br /> E Hauler IN me City,State and Zip . <br /> BRA�INON TIRE Stamp orLabel OK <br /> /LJE`��t'�IyQ/L�eieAr�1'{/^�((��7p'�)'�'��'�•)1���/� aa���■a�� <br /> Address Same asHauler'• r � <br /> I CERnFT THAT UNDER PENALTY OF PMURY OF THE <br /> WRQ nm) <br /> V TV VT <br /> IN i UM OF THE STATE OF CAWWTH <br /> ORA THAT E <br /> I FO N M D ABO S TRUE AND ECT O <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> :3520281 __ B Pick Up © Delivery a <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> DATE DD ®o as ... <br /> u o.Whole The Count E]Welght <br /> In Lbs. <br /> 1101011191 9 4 1 Facility Business v <br /> `y0,Volume Cubic Yds.'[]Weight in Tons' .Name/Address r L <br /> E -City State an,Zip <br /> �AANK N TIRE- -. <br /> V p or Label OK <br /> a <br /> eleppq _f�lyrpt � ■ Address Same as Hauler <br /> (N%Airor •L n TWIT7An0FCAUF0'OFPER T E THE- <br /> . :1MioN .uw6 of rHe srATe of CAIIF-0Rxu THAT TILE . <br /> INFORNAnON�PRO DEO ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Loada ,I g Site Suffix <br /> 0 3.520281': -- A. Pick). Delivery' <br /> Hauler Tire Program ID. / Site Suffix Facility Telephone Number <br /> is w- ` hole.Tire Count []Welght In Lbs. <br /> ODE' E00000E <br /> 1101011 9 9 4 1 F 'Iity B Sin <br /> E �❑rVolume.Cubic Yds.[]Welght In Tons <br /> NANNON TIRE �.s7`. <br /> COOED.00 <br /> 1(800Y'2fgf t4Y3 Address Same aE Hauler <br /> (N/A for �CERTIFY i1NT UNDER PEr1ALTY OF PERJURY OF THE <br /> ' jole Tim) uWS OF THE STATE OF CALIFORNIA THAT THE <br /> I 'INFORNA71ON PR2g2L=9 IS TRUE AND CORRE . <br />