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trH %.0mprU11U1151vU 1 Flip LU9 d11U r[U1L;Fd1PLS Iuuuz P.O.Box 1259,Sacramento,CA95812-1259, Comprehensive Trip Number 3220993 CIWMB203�loiOs)INSTRUCTIONS ON BACK O T 2 DO NOT TAPE, STAPLE OR DU ATE 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 at seq.,If a request Is made for disclosure of this information,the CIWMB will contact the signer(s)of this format the address and telephone number provided on this form or receipt Truck Decal Number Hauler Address n� Business Name Address fill D lam" City, State and Zip License Plate Number State p� Carrieron 01 j 3" I certify under penalty of perjury under the laws of the State 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 th Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to$25,000 per day,perviolation or administrative enaIII up to$5,000 per violation per day as described in Public Resources Code section 42962 Z . 1� Ass.g 6 Drivers ame(print) Drivers ignature Date Comprehensive . . Number Load Information Facility Tire Program r 9 3 -- C Pick Up Delivery 0 a s UI�UU-0 Hauler Tire Program ID / ffix ATE �a / a Facilit ephone Number y o-oaa0000 W ❑ Whole Tire eight in Lbs. m a acility Business m r11� El Volu is Yds. Weig s Name/Address E Hauler Name tate and Zip M 7 H v � Stamp or Label OK Hauler Telephone Number ---� TDOODMOD a [] Address Same as Hauler Initials (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE - Whole Tires) LAWS of THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID S 3 2 2 0 9 9 3 -- Pick Up Delivery ® � W k-rd 0 P1161_0 Hauler Tire Program ID / Site Suffix :DATE �o / /r Facility Telephone Number wn Whole Tire Count Weight m Lbs aoo-oa000ao ti Facility Business r Volume Cubic Yds Weight in Ton Name/Address U,g,TIRE SERVIC Hauler Name City, State and Zip 2014 S.EI Dorado Streai Staddon,CA 96206 �,) ' �� 1 tp DI Stamp or Label OK ( 1 ?� . a Hauler Telephone Number [] Address Same as Hauler Initials (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE t Whole Tires) "AWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive • ••• Number • • Information • • 1 Site Suffix 3220993 -- A Pick Up ❑ Deliveryy DATE a / Facility Telephone Number LE Hauler Tire Program ID / Site Suffix w Whole Tire Count Weight In Lbs ooa-aooaaoo a FaciliGQLI€ I B�'-�'r��®r d Volume Cubic Yds. aWeight in Tons Name/Address !Q, $OX 1 Hauler Nam _ City, State anShico,CA 95303 M� t„i16i ( 1'p E_ 2 a -3tamp or Label GQ9) 668-4855 Hauler Telephone Number a Address Same as Hauler Initials f or I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE L'3 - (� /J ��,� Whole(N lA for reS)�s LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.