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r - — — — F— --0 r-••r• w v v■M u r.U.tsox tzby,Sacramento CA 95812—1259 <br /> ==e.e i tllll P L E ! 3 -: � �Q . <br /> Com rehensive Tri Number <br /> NN 3026550 <br /> INST TIONS ON BACK RT 2 DO NOT TAPE STAPLE ORAT <br /> GWMBM71ar/45) <br /> By signing this CA ComprehensnnsTr(p log and Receipt the signers)request that the Information provided on this form will be considered confidential,proprietary and trade secret.In accordance with Title,14 CCR,Section <br /> 17041 et 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. <br /> Truck Decal Number Hauler Address b <br /> Business Name <br /> [o] ® © © D ® D <br /> License �6Js- <br /> Plate Number State Address <br /> © ® ® D D © City, State and Zip <br /> I certify under penalty of perjury under the laws of the State of California that the information provided above is true and comect.In addition,1 am aware that falsification of this information may result in suspension,revocation,or denial of renewal of the <br /> 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$5,000 per violation per day as described in Public Resources <br /> Code section 4296 <br /> Driver's Name(print) Driier';-.—S igactureComprehensive Trip Date <br /> . . Number Load Information FacilityProgram <br /> Q0 <br /> 3-_26 5 5 0 -- C ❑ Pick Up ❑ Delivery <br /> DDDDDDD Dfl <br /> 4) Hauler Tire Program Suffix FacilitNumber <br /> .. DATE <br /> to <br /> M D-DDDDDDD <br /> U, ount Weight inLbs. <br /> Facility Business <br /> Volume Cubic Yds. ht in Tons <br /> Name/Addra— <br /> o <br /> H Hauler T one Number <br /> Fm _� � Initials <br /> Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> for Whole The Count LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. ' <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> Co <br /> 3 0 2 6 5 5 0 -- BPick Up Delivery aI ( ( 0 t <br /> °U' Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> V) g DATE 11D,/ 'LLLJJJ oDD-DDDDDDD <br /> to a Whole Tire Count Weight in Lbs. <br /> 2 } Facility Business <br /> t- Volume Cubic Yds. Weight in Tons <br /> E 4 c ty, and Z y-P 0DUCT% <br /> Box <br /> (�j Hauler Telephone Number 1w, 1 <br /> c i 11111111 Stamp or Lal)U08k,0,CA 95M3 _ <br /> Q ■ 0 (M)ffig .""`^r' Initials`;'. ,'-�`�' <br /> Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE ,_s <br /> for.Whole Tire Count INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. ,. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 3026550 -- Qa•Pick Up 1:1 <br /> Delivery 111, 0 D <br /> 7/115 <br /> : �� i_- j 0 0 <br /> Hauler Tire Program ID / Site Suffix / a00 / n� Facility Telephone Number <br /> DATE IL_.JC <br /> Lu Whole Tire Count Weight In Lbs. 11 . <br /> 2 <br /> DDD-DDDDDDD „ <br /> LuFacility Business <br /> Volume Cubic Yds. Weight in Tons <br /> Narqe/Addy <br /> E City, State and Zit2 <br /> y Hauler Telephone Number P.O. Box 1 <br /> v g Stamp or La6t4161ko, CA 95303 <br /> (209) 668-4855A / <br /> ■ tnitials I f li <br /> Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> for Whole Tire Count LAWS MAOFTHE STATE OF CALIFORNIA THAT THE <br /> INFORTION PROVIDED ABOVE IS TRUE AND CORRECT. \ /" <br />