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California Integrated Wase .gement Board CA Comprehensive Trip Log and Receipts P.O.Box 1259,Sacramento,CA 95812-1259 E'X A,;1ii P j L E i:2 3 I _ Comprehensive Tri Number INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATI30249I 2 7 Ry signing This CA Comprahenslve TripLog and Reccipl,the signerls)request Ilial the Information provided on this form will be considered confidential,proprietary and trade sac ret.In a,,,,d,n,,with title,14 CCR,Section 11041 et seg..If a reV,—Is made far disclosure o!lhi�:Information,the CIWMS will contact the signer(s)of this form at the address and telephone number provided on this form or receipt. _ Vehicle Information Truck Decal Number Hauler AddressP E 11 D 1111-0 Business Name LIcFn e Plate Number I - _ �• State Address I• 00 0 0 0 0 0 0 City,State and Zipf``'f norhty under penally of perjyry untler Ilia laws of it,,.Slate d C.1do-c that Ins inlormalion provided above Is true and coned.In addition,I amaware las f�a s°liieeUOD of this Information may result in suspension,revocation,or denial or renewal of the W rile Tire Hauler Re jaGallon pursuant la Public Res p`,ur 1Coda section 43980 end may result In o,11 peneltles up to 111,111 per day,par Wolallon or adm nisi Iive)leneltas up to$5,000 per violation per day as descrlbed In Public Resources Lotle section 42962 Driver's Name(print) river's Signature Date Comprehensive Trip .. Number Load Information Facility Tire Program ID Site Suffix 3024927 -- C Pick Up ❑ Delivery — Hauler Tire Program ID I Site Suffix Facility TeleNumber phone � DATE / 00 / Lu El Tire Count Weight in Lbs.- L-L' 00 - r� 0a . 00 4�) 11 [Facility Business El Volume Cubic Yds. Weight in Tons Name/Address E - o City,State and Zip Hauler Telephone Number f � Stamp or Label OK E Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE LAWS OF THE STATE OF CALIFORNIA THAT THE I"- fOrWholeTlreCOunt INFORMATION PROVIDED ABOVE IS TRUE AND COP.RECT. Comprehensive I Log NumberProgramiid' 3024927 -' ® Ll Pick Up 0 Delivery 0 0 —� °U Hauler Tire Program ID I Site Suffix Facility Telephone Number DATE �� N 000-0000000 L Whole Tire Count Weight in Lbs. ❑Volume Cubic Yds. Facility Business weight in Tons Name/Address o I _ - '— City,State and Zip 'L� Hauler Telephone Number aStamp or Label OK 11 E F 11 11 n J i1 Initials Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE for Whole Tire Count =l0FTHE STATE OF CALIFORNIA THAT THE "" INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip •• NumberTire Program ID Site Sluffik�'-� 3024927 -- Pick Up ❑ Delivery 0 0 1 n 10 U L 11—U U Hauler Tire Program ID / Site Suffix DATE / / Facility Telephone Number LU Whole Tire Count Weight in Lbs. 00000000 > Facilit Business t- E]VolumeCubic.Yds. Weight in Tons y `m Name/Address o I City,State and Zip U Hauler Telephone Number a p 1111 E Stam or Label OK Initials —1 Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE for Whole Tire Count j LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. o1 � c) z� v3 I �Il