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vM vvlIIPI VIIV[IaIvc I I IF •..vaJ, all%A .l IF 4-7 rva •------- <br /> jEjXjAjMjPjLjIflf 11Comprehensive Trip Number <br /> 3220995 <br /> 5vb,rca„�ml. 2 DO NOT TAPE, STAPLE OR DU E <br /> cnvMe2oa(loloa)INSTRUCTIONS ON BACK <br /> 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,1 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 form at the address and telephone number provided on this form or receipt <br /> Truck Decal Number Hauler Address <br /> Business Name <br /> Address -- <br /> LL,f[JJ L� City, State and Zip i 1�6 <br /> License Plate Number State <br /> )a ❑ Common <br /> ® a a a a ® a © a Carrier <br /> 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 <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 ad-,n,str.t,ve p nalties up to$5,000 per violation per day a described in Public Resources <br /> Code section 4 l���C�� � <br /> Driver a(print) Driver's Signature Date (l 6 <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Sitc Suffix <br /> CL 3 2 5 -- C [:] Pick Up ❑ DeliveryDoer-Tor”! <br /> 41 Hauler Tire Program ID I Suffix Facility Telephone Number <br /> DATE / / <br /> y . . aoo-a000aao <br /> Whole Ttr nt Weight m Lbs. <br /> Facility Business <br /> y Volume Cubic Yds. Wei Tons Name/Address <br /> E Hauler N City, State and Zip <br /> U <br /> Stamp or La <br /> a Address Same as Ha <br /> Hauler Telephone Number ■ Initials <br /> (N IA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) 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 /> 3220995 -- B 0 <br /> Pick Up Delivery <br /> Hauler Tire Program ID / Site Suffix DATE Facility Telephone Number <br /> �a ,/ /" �a <br /> w Whole Tire Count Weight In Lbs. <br /> EL r r Facility Business <br /> ') Volume Cubic Yds- Weight in T Name/Address <br /> ❑ U.S.TIRE SERVICE <br /> Hauler Name City, State and Zip 2014 S.EI Doradio Strebt <br /> Stockton,CA 95206 <br /> QStamp or Label OK <br /> Hauler Telephone Number ■ Address Same as Hauler initials <br /> (N'A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE F , <br /> 1Whole Tires)= LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> w.r l INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Ow <br /> 3 <br /> 220995 -- A Pick Up Delivery E <br /> ® ©-�nn <br /> © �J <br /> Hauler Tire Program ID / Site Suffix DATE / / Facility Telephone Number <br /> oa oa. o <br /> . aoa-000aoao <br /> wWhole Tire Count Weight In Lbs. <br /> r s <br /> CL (Facility Business <br /> f a � � D ; ❑ Volume Cubic Yds. Weight in Ton Name/ dy�r P OT�UCT 'INC. <br /> ler m 9 Cit �stttf�"�ti� <br /> 7 O, Box 1 <br /> f �f��' E Stamp or Lglj , CA 95303 <br /> a Address "*6gla)866 ' <br /> Hauler Telephone Number ■ I'll <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE 1 <br /> `�J IN for LAWS OF THE STATE OF CALIFORNIA THAT THE I <br /> �; 1-16'1 /.., Whole TIfE 4) INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />