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California Integrated25,Sac Waste Management 1Board <br /> 259 <br /> ,-;A_Comprehensive Trip Log and Receipts P.0.Box 1259,Sacramanto,CA95912-1259 <br /> ' E,''X AIJi l P E L 2�' -- Comprehensive Tri Number <br /> INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATIJ 3024924 <br /> By signing this CA Comprehensive Trip Log and Receipt.U,e snnnH,)regnetil Ihat the Infwmallon provided on this loan will be considered eonfid-UM <br /> ,Propnetary and bade sacral.In accordance with Title,14 CCR,Section <br /> IM" <br /> cl seq..If a request Is mativ ler tllsclasury of this inh.in,:•lion,the CIWMB will contact the signer('(of this form at the address and telephone number provided on this farm or receipt <br /> VehlCIe Inf0rnl atl0n <br /> Truck Decal Number Hauler Address F— 66-.5 );:�'-)" y.,., <br /> r Business Name <br /> 00 - 0000 0 6 <br /> License Plate Number State Address <br /> 0 0 0 0 111111 City,State and Zip <br /> ashy nnaer penally of I niury'neer Ile laws ql Ure sial'—CalJprnia Ilial the informs on provided apove b We ane camel n aanr,I aryl aware Ilial lalsKcalion of IMs information may insult In suspension vocaM.,or dannIl of renewal of the <br /> CWa'ste�TiGreroH..1.1 2 egsValion pursuant m Fnblk Res w" Code/cion 42960 and may reaull In evil pananlaa op to a zs.000 per day.per Nda4on t�admmislratiy�e penalties Up to$5.000 per vicar par day as described In Pubcc R—umes <br /> Driver's Name(print) Driver's Signature Date <br /> .,comprehensive Trip Log Number Load Information <br /> Facility Tire Program 113 Site Suffix <br /> Q 3 0 2 4 9 2 4 -- C Pick Up jinLbl. <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> DATE0- ElWhole Tire Counfr l a �� >- 1Fcility BusinessI,�!_ '� r �- �(�' ❑VOILI111e Cubic Yds. <br /> E Name/Address <br /> o City,State and Zip <br /> m Hauler Telephone Number 1t <br /> 11111111 Stamp or Label OK' <br /> .110 <br /> ninafs <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 /> it <br /> 3024924 -- ® 7DF ck Up ❑ Delivery <br /> Hauler Tire Prot ram ID / Site Suffix FacilityTelephone Number <br /> LL JJ <br /> � � / / pEon-00000001 <br /> m } �Whole Tire Count �Weight in Lbs'. <br /> Volume Cubic Yds.❑ g Facility Business <br /> v Wei nt in Tons Name/Address <br /> o City,State and Zip <br /> Hauler Telephone Number a <br /> Stamp or Label OK <br /> 11111111.11 � <br /> InfOals —! <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 /> Comprehensive <br /> • •• ProgramF Tire <br /> 3024927 -- A Pick Up every U :J <br /> Hauler Tire Program ID / Site Suffix / / Facility Telephone Number <br /> DATE � �a®0000000 <br /> N <br /> w <br /> uJ ❑Whole Tire Count Weight in Lbs. <br /> Ir– Volume Cubic Yds. it Facility Business <br /> !, ❑ Weightin Tons Name/Address <br /> o City,State and Zip <br /> Hauler Telephone Number <br /> L' a Stamp or Label OK <br /> Wh0Ie Tires 01TIy (CERTIFY THAT UNDER PENALTY OF PERJURY OF TIIE <br /> for Whole Tire Count LAWS OF THESTATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> 1 <br /> z 0 <br /> 1� � lT-ill✓ �'f� _ I'� r r"� � � � ,- <br /> J <br /> ^ I 1 r <br /> 1 I <br />