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California Integrated Waste Management Board <br /> ACA Comprehensive Trip Log and Receipts 0002 P.O.Box,z59,Sacramento,CA958,z-1259 <br /> IEIXIAIMIPILIEI IIICom rehensive Trip Number <br /> . sren or aqr mi. �.:• <br /> ClWM82gJ(1gfOv5)INSTRUCTIONS ON BACK OF PART 2 DO''NOT TAPE, STAPLE OR DUPLICATE 3248531 <br /> By signlrg 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 al seq.,If a request Is made for disclosure of this Information,the CIWMB will contact the signer(S)of this toren at the address and tolephons number provided on this form or receipt. <br /> VeHIMe Information <br /> Truck Decal Number Hauler Address F _ L <br /> Business Name -/�� �"�-i*/"` i� - �`"��^� <br /> — a �.. Address 0 /3 <br /> City,:State and Zip <br /> License Plate Number State <br /> a a o a Cam e on <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 resull in suspension,revocation,or denialof renrenewal of th .j <br /> Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to$25,000 per day,per viotafion o inistrab a penaNes up to$5.000 per violation per day as described in Public Resources <br /> Code section 42962 <br /> Driver's Name(print) Ignature ate. <br /> Comprehensive Trip .. Number Load Information Facility Tire Program <br /> i <br /> x <br /> 3248531 <br /> -- C Pickup a Delivery <br /> m <br /> Hauler Tire Program'ID 7 'Site-Suffix Facility Telephone Number <br /> y DATE <br /> oat-©a000ao <br /> cy wa `Whole The Count �Weight In Lbs. <br /> & t siness <br /> £ Uuler 3� I ~ ❑ Volume Cubic Yds.�Weight in Tons FCam�Add�ss .Zi o Na e a P <br /> Q ■ Address Same as Hauler mrna/ I <br /> Hauler Telephone Number <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) 11 OFTHE STA TE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 3248531 - B NIPickUp Delivery <br /> � N,7,,, Facility. umbef <br /> Hauler Tire Program ID / Site Suffix DATE / HM <br /> W Weight in Lbs. <br /> a :Whole Tire Count � g <br /> i ility Business <br /> d , 3 Volume Cubic Yds. Weight In Tons s <br /> • o -Hauler Nam and Z • <br /> W �N- A\ S J�1 • <br /> 3 - V ` , _ $tam Or�a13E7 lllC . <br /> Hauler Telephone Number ' ■ Address Same'as Hauler. /brr/a/S —J <br /> 0';, <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF.PERJURY OF THE ' <br /> J WIN/ for LAWS A TOE STATE OF CALIFORNIA THAT THE, <br /> INFORMATION PROVIDED ABOYE IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 32 4 8.5-31 _t. A Pick Up � DeliveryUA INT © 0-9, U <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> I - y <br /> DATE <br /> m nw. EJ-Whole Tire Count Weight In Lbs. <br /> NEE-000P00 <br /> !. Fac B��+u+/s�i <br /> w I t E] Volume Cubic Yds. Weight in Tons Na !tictfe <br /> City, Stale, Zi <br /> o Hauler N�eF' ^ t. <br /> a <br /> gtakr or� <br /> Hauler Telephone Numb r ■ Address Same e's'Ha er <br /> P <br /> ' '} (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> y /�i r C / j .LAWS OF THE STATE OF CALIFORNIA THAT THE , <br /> f `� r J Whole Tires) INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.- <br /> 00011 d$o <br />