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11.0/'1 1110V111C 111P L.VLjj 011U I%CL.CI'JL7 IVVVL 1.V.0iJX. a,an nrenro,i.r+aao.c—icaa <br /> .•.:. �`_ � <br /> Comprehensive Trip Number <br /> lEjjXjAjW1P1L1e1it <br /> Stat, f 220994 <br /> CIWMB (203ir os INSTRUCTIONS ON BACK O T 2 DO NOT TAPE STAPLE OR DUWE <br /> 1 <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,14 CCR Section <br /> 17041 at 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 ) J (� <br /> Business Name <br /> Address <br /> License Plate Number State City, State and Zip , ,�) s\ <br /> CarrCommon <br /> ie �� <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 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, iolation br administra0ve It up to$5,000 per violation per day as described in Public Resources <br /> Code section 42962�� � <br /> a 6 <br /> Driver's fl-37110r(print) b river's gnature Date <br /> Comprehensive Trip Com . . Number Load Information Facility Tire Program <br /> a prehensive T' <br /> 32 4 -- C Pick Up ❑ Deliveryis <br /> Hauler Tire Program ID / 1 x F Tele hone Number <br /> n p <br /> JT <br /> . aao-aa000ao <br /> LU Whole Tire Co eight In Lbs. <br /> a. <br /> Facility Business <br /> `m me Cubic Yds. Weight in o amelAddress <br /> Cit nd Zip <br /> p <br /> o Hauler Name <br /> in <br /> v Q Stamp or Label OK <br /> Haute phone Number ■ Address Same as Hauler Initials <br /> (N/A 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 • • Information •• 1 Site Suffix <br /> Y3220994 -- B Pick upr Delivery: <br /> Hauler Tire Program ID / Site Suffix DATE Facility Telephone Number�a � o� / �' p <br /> CL ® Whole Tire Count �Weight In Lb , <br /> 0H@_HEEEHER <br /> CL Facility Business <br /> Volume Cubic Yds. Weight in Toy Name/Address U.S.TIRE SERVICE <br /> City, State and Zip <br /> Hauler am r—' .r 2014 S.EI Dorado Street <br /> j, Stockton,CA 95206 <br /> Stamp or Label OK <br /> a <br /> Hauler Telephone Numbe Address Same as Hauler Initials <br /> (N/A 1 CERTIFY THAT UNDER,PENALTY OF PERJURY OF THE /- J <br /> Whole Ti r s '° LAWS OF THE STATE OF CALIFORNIA <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. I <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 3220994 -- /4 , d'+ Pack Up Delivery <br /> 4 <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> DATE - / HE'/ <br /> Whole Tire Count Weight in Lbs r <br /> 000-oa000ao <br /> " iiity Business <br /> VIZ>1512— D ~ Volume Cubic Yds. ❑Weight in Ton' Naine?Address <br /> Hauler Name - City(l t0j)N j '.RRODUCTS,LNC. <br /> O. Box 1 <br /> f Stamp or Lal <br /> .-a ��CA 95303 <br /> a ! _ Address�i,��S,F�ai,i�r� <br /> 4lyok dQa-` t� Initial <br /> Hauler Telephone Number ■ ICERTIFYTHATUNDERPE J Y <br /> C/ �L `_ � � (N/A for <br /> Wholires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> �-� e T <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />