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ka x ❑E [ IVuh.1 <br /> _ - ` � - 3024922 <br /> 5�re °)i°m,a INSTRUCTIONS ON BACKT 2 DO NOT TAPE STAPLE ORD T <br /> GM1YMa I03(ar105) <br /> By signing this CA Comprehensive Trip Log and Receipt,the signer( the information provided on this form will he considered cont demi nd trade secret. ei 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 signers)of this form at the address and telep�ne numb ro don this form or receipt <br /> Vehicle Information r <br /> Hauler Address ❑— .;% ❑ <br /> Truck Decal Number <br /> — ❑ ❑ ❑ ❑_ ❑ Business Name '� y>~ <br /> License Plate Number state Address , r1 <br /> ❑ ❑ ❑ <br /> D D City, State and Zip <br /> proviWenify un Hauler Registration pursuant to Publ'c Resouate mesfCalifornia Code secdonat the 42960 and may resultrmationdin cived b penaltiesup to$25 00ove Is true and correct0 per dIn ray,per v ola0 n_admin stcaltrve�ienal0 so up to$5,000 per violatiotion may result in n per day as described in Public Resources <br /> ension,revocation.or de—I of renewal f the <br /> ste <br /> Code section 42962` ter- Jam_ ` / �� L�.•� <br /> f i s / <br /> Drroer's Signature <br /> Driver's Name(print) Date <br /> . . . Information Program <br /> Comprehensive Trip . . • <br /> __ f Pick Up Delivery ! -� ❑ ❑—❑ .❑ <br /> r 3024922 C ❑ ,❑ ❑ ❑ ❑ ❑ <br /> U <br /> ❑❑iF <br /> Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix <br /> � DATE ❑❑ / t.. . �'' � ,_ _ ,.- <br /> . ❑ ❑ ❑ <br /> w r}Whole Tire Count Weight m Lbs. <br /> a acility Business <br /> ' ❑ Volume Cubic Yds. ❑Weight in Tons Name/Address <br /> City, State and Zip CA-. <br /> i��'•�t <br /> w Hauler Telephone Number <br /> r- Stamp or Label OK <br /> '-✓tiQ ■ Initials <br /> r Whole Tires Only 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE IV for Whole Tire Count INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> __ Up Delivery3024922 [] Pick <br /> � ❑❑ Facility Telephone Number <br /> 01 Hauler Tire Program ID / Site Suffix DATE / %� ❑ <br /> W ❑Whole Tire Count ❑Weight 1n Lbs. <br /> a Facility Business <br /> tom- ❑ Volume Cubic Yds.[:]Weight in Tons Name/Address <br /> City, State and Zip <br /> E <br /> Hauler Telephone Number <br /> Stamp or Label OK <br /> U <br /> Q � Initials <br /> 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires Only <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> for Whole Tire Count INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> r __ A Pick Up Delivery ❑ ❑ ❑ ❑ ❑ ❑—❑ ❑ <br /> ,s 3024922 ❑ ❑ <br /> E Facility Telephone Number <br /> U DATE ❑❑ / ❑❑ � ❑❑ _ <br /> Hauler Tire Program ID I Site Suffix ❑ ❑ ❑ ❑ ❑ <br /> W ❑Whole Tire Count ❑Weight in Lbs. <br /> CL Facility Business <br /> e ❑ Volume Cubic Yds. []Weight in Tons Name/Address <br /> E City, State and Zip <br /> °, Hauler Telephone Number <br /> i— Stamp or Label OK <br /> V Q Initials <br /> Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> for Whole Tire Count INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> { /7 <br />