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• <br /> CA Comprehensive drip Log and Receipts California Integrated Waste,.anagement Board <br /> P.O.Boa 1259,Sacramento CA 95812—1259 <br /> C X A A' P i D' 1? 2 3 _� .� Com rehensive Tri Number <br /> INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICAT 3024923 <br /> By si9ning Illi,CA Comprehensive Trip Log and Receipt,111, request That the information provided on This form will be considered canfldentlal,propyl-ry and bade sec-t.In Ha,—wish Title,14 CCR.Section <br /> 17041 a sen.,If a request Is made for dlsciasura of hl, a CIWMB will contact the signer(,)of this form al the add,,,and teiept,ono number provided an this form--eiplc r <br /> -Vehicle Information i <br /> F... <br /> Truck Decal Number Hauler Address fry✓ c-a'6 <br /> Business Name <br /> License Plate Number. Stale Address <br /> City,State and Zip L-- J <br /> I-Rily Under penally of perjury under the laws of In,Stale MI California that the Information molded above Ia Irue antl correct.In addition;I am aware that falsilicalio 6W s Informa0on may result in suspension,revocation,or denial of renewal of Iha <br /> Wesle Tha Hauler Regletre8o newt to Public Resources Code secll-62960 and may react(In civil penalties Up <br /> to <br /> $25,000 par day.par Aolalion or ad 66440.pa IOst up b$5,000 per violation par day as d...dead In Public Resources <br /> coda saclbn 42962 / / <br /> Driver's Name(print) Drivers Signature Date <br /> �-!Comprehensive Trip .. Number <br /> 3024923 -- C Pick Up ❑ Delivery ( — <br /> Hauler Tire Program ID I Site Suffix Facility Telephone Number <br /> N DATE 00 / [10Doo-aoa_®Doo <br /> � a �Nlhole Tire count Weight in Lbs. � <br /> > I Facility Business / <br /> I ;. '} ��/ tii r Volume Cubic Yds.0 Wei ht in Tons r <br /> j'� •, g Name/Address <br /> E f City,State and Zip C-A <br /> Hauler Telephone Number ml OK ` `=G /a•—f ,�^ r>?/ <br /> Stamp or Labe � 1 <br /> ,'� � 1 ■ mluafs <br /> yi;r d Whole Tires Only ( l; <br /> 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> for Whole Tire Count - LAWS OFTHE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIOEO ABOVE 15 TRUE AND CORRECT. <br /> ComprehensiVe a <br /> ,Log Number ..Load.Information Facility TlrePrclgrarn ID ite.Suff' <br /> 3024923 -- B ❑Pick Up 11Pick <br /> Hauler Tire Program ID / Site Suffix DATE / / Facility Telephone Number <br /> C: LIJCL Whole Tire Count 0 Weight in Lbs. <br /> 000®0000000 <br /> r E] Fay <br /> cilit Business <br /> a Volume Cubic Yds.[:]Weight in Tons <br /> m Name/Address <br /> E — — City,State and Zip <br /> o <br /> CITIF <br /> U0pHauler Telephone Number <br /> Stam or Label OK <br /> murals <br /> Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> for Whole TI fe C O LI n t LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> .Comprehensive . as Number� Facility Tire Program ID Site slu <br /> 3024923 -- A �Pick Up ❑ Delivery E E 0 0 0 E 0-07 <br /> Hauler Tire Program ID I Site Suffix DATE / / Facility Telephone Number <br /> � a �Whole Tire Count Weight in Lbs. <br /> _Doom-0000 <br /> a- I Facility Business <br /> I— E]Volume Cubic Yds.❑Weight in Tons Name/Address <br /> d <br /> E City,State and Zip <br /> NHauler Telephone Number <br /> v a a Stamp or Label OK I <br /> ■ mrnara <br /> Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> for Whole Tire Count LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />