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CA Comprehensive i rip Log ana meceipt5 r.U.box lLott' ay oacrannoro,�.., - :. E[XIa � P L E 1 2� Com rehensive`'9'ri Number SyreerC""Mis BACK OF F.,riT 2 DO NOT TAPE STAPLE OR DUPL._ .rE 3026550 CIWS?9 SOJ(04)(16) INSTRUCTIONS ON By signing this CA Comprehensive Trip Log and Receipt,the signer(s)request that the information provided on this form will be considered confidential,proprietary and trade secret.In accordance with Title,14 CCR,Section ' 17041 et seq.,If a request Is made for disclosure of this information,the CIWMB will contact the signer(s)of this form at the address and telephone number provided on this form or receipt. Truck Decal Number Hauler Address F ❑ ❑ ❑ ❑ ❑ ❑ ❑ Business Name License Plate Number State Address 11111111 ❑ [10 City, State and Zip I certify under penalty of perjury under the laws of the Slate of California that the information provided above is true and correct.In addition,I am aware that falsification of this information may result in suspension,revocation.or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000per violation per day as described in Public Resources Code section 42962 Driver's Name(print) Driver's Signature Date .. 3026550 -- C Pick Up Delivery ❑ ❑—❑ ❑ Facility Telephone Number ° D ❑❑ / ❑❑ / ❑❑ Hauler Tire Program ID / Site Suffix ATE •� a ElWholeThe Count ❑Weight in Lbs. ❑ ❑ la f acility Business ❑Volume Cubic Yds.❑ ` Weight in Tons Name/AddrPs- E ° Hauler Telephone Number n f-- .. LAWS OF THE Initials Whole Tires Only T UNDER PENALTY OF PERJURYE THE STATE OF CALIFORNIA THAT THE ,;for Whole Tire Count INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. ' Q 5 0 -. B Pick Up Delivery MUD � 3® 0— D 30265 ❑ Facility Telephone Number 0 Hauler Tire Program ID / Site Suffix i N DATE ❑❑./ ❑❑;/ D '.. w 1Nhole The Count ❑Weight in Lbs. ❑ ❑ ❑ ro y Facilit Business ❑ Volume Cubic Yds.❑Weight in Tons Nam AY-PRODUCTS,kNc- E City, to a anfnl�t�.Box 1 Hauler Telephone Number � ,,CA93W Stamp or La U Initialsid Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE LAWS OF THE STATE OF CALIFORNIA THAT THE for.Whole Tire Count INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 3026550 -- A `�� Pick Up ❑ Delivery �� ❑ �� © ❑�❑''❑ Hauler Tire Program ID / Site Suffix Facility Telephone Number DATE O[J/ ❑❑/ wa ❑Whole Tire Count ❑Weight in Lbs. ❑ ❑ ❑ 03) � rFacility Business l- El Volume Cubic Yds. ❑Weight in Tons Na e/,pdry m City, State and ZlpO SOX 1 'L� Hauler Telephone Number ap CA 953Q3 Stamp or La 1 j a (209) 668-4855 � _ )hats ~ Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE LAWS OF THE STATE OF CALIFORNIA THAT THE for Whole Tire Count INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.