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CalHomis Integrated Waste Management Board <br /> CA Comprehensive Trip Log and-Receipts 10002` P.o.Box 1289,Sacramento,CA95812-1259 <br /> Com rehensive Tri Number <br /> INSTRUCTIONS-ON BACK.OF PART 2 DO NOT TAPE'STAPLE;OR DUPLICATE 4 0 6 0 14 6 <br /> - By sipntlp tic CA Compreh•nsNe Trip Lop and Rce[K On aigner(s)request aur the fift adon provided on tide form witl be considered confidential,proprietary and end•secret In accordance•1th This,14 CCK Section <br /> 1741 at sea•Ifs regrsH Is made for disclosure of this hdormatlon;tis CIW1®Mtl eoreact the sionsi of Dds format the address and telephone numbw provided on Mb fomn or recNPL <br /> , Ve is e;1n ormation.7r} <br /> Hauler Address <br /> ', -xi- Truck Decal Number ) , <br /> Business Name I ( C_ -Did f 0,, <br /> City,-State and Zip- <br /> License Plate Number State Co7 Q ' Cif �S v <br /> P "FflD Cs�ds ' <br /> BE0mmon, <br /> R ,Carrier, <br /> 1A <br /> I certify under penalty of perjury under the laws otthe'State of California that the iniormation'provided above is true and wrrect.In adddion•I am aware that falsification of this inlormation may result in suspension,revocation•or denial of re—ne : <br /> Waste Tire Hauler Registration pursuant to Public Resources Coda section 42960 end may result in civiLpenegies up to 526,000 psi day:Dervbletion or.adminisaativri penalfiei up to <br /> per violation per day as deicribed in Public Resources_ <br /> Code SeCIWn4 <br /> r <br /> i Driver's=Name riot Driver's Signature <br /> 'w3 <br /> a•''• - Comprehensive Trip Log Number Load Information • • t Site Suffix •'+ <br /> r <br /> CIL <br /> M-- C Pick 'Delivery <br /> 4060146Up . ❑ ❑ � ❑ ❑`❑ ❑ ❑ <br /> Hauler Tire Program ID ;Site Suffix Facility Telephone.Number .: <br /> DAT <br /> yE.�� / ❑ /. <br /> w ❑ Whole Tire Count ❑Weight In Lbs <br /> g a i aciii i-. rrFSS <br /> THauler <br /> Volume Cubic Yds.[]Weight In Tons �larnsfauler Name• Address Same asHauler"Telephone Number 0 <br /> (N/AT <br /> nor I cE7cr>Fy THAT UND IM PENALTY OF PERAiTi OF THE Whole Tlrss) uW8 OF TIDE STATE OF CALIFORNIA THAT THE 1 <br /> MFORYA71 IN PROVIDED ABOVE 15 TRUE AND CORRECT. <br /> Comprehensive Trip Log Number • r Information .I <br /> a <br /> A 0:6 0.14'6 - B. Pickup 0 Delivery <br /> Facility Telephone Nlumber , "f <br /> Hauler Tire Program ID / Site Suffix DATE <br /> c ti r , Wel ht in Lbs. <br /> UJ Whole Tire Count g ( . r <br /> a bac it C3i.s�lnss: i / <br /> `m G Volume Cubic Yds: Weight In Tons -Ria rftgC3E•�'�5::,•f_• • :�+� {.Z t~ '. <br /> o Hauler Name <br /> .. .;,._ _ �'. ...�C /ice. ��✓.e.: - � <br /> p.SCIO <br /> _ ED t� � � r� 31 <br /> 3 . y <br /> a !.• i Address Same•as Hanie'r <br /> Haslet Telephorie;NumSer <br /> r�I �• r t - '-'(N/A for .I CERT4Y THAT UNDER.PENALTY OF PEIUUIIIY OF <br /> - �V i .� 7 �.. �' •1 /.�- _ Whole-nnii. -:aWill OF.71(E STATE OF CAL1FOF UA THAT TRUE CORREC <br /> 7HE... <br /> .. _ .DLFORMATION FRONDED ABOVE 99 T. J 4 <br /> • rInformation• • • • - ••• r - <br /> Site S <br /> 4 0.6 01.4 6 <br /> Haul <br /> M.j0� ; Pick Up ❑ Delivery: <br /> Facility Telephone Number . <br /> '.•' <br /> lwzi <br /> /�ef The Program ID l' uffix <br /> - 'DATE <br /> 99 ' . .Elfl .. . ao <br /> _ w ❑✓ Whole The Count El <br /> Weight in Lbs.. <br /> Ili <br /> a Volume Cubic Yds1(�,a3iness <br /> m / O.6O b.1 J l I6y 1 . < Weight Tons -•-V1@n='���35g : 1 <br /> £ ❑ . ht il�� V, CC W A� <br /> o Hauler.Name <br /> r ti -'rt7 5 eta ,,010 L�sj Q�t . q�L o.. . <br /> Hauler Telephone Number a a Address Same as HaulerDUDE <br /> (N!A for I CEE1!nFY THAT UNDER PENALTY,OF PoLIURy OF THE <br /> .V.�. S•y S+ tNh010 Tires), LAWS of THE STATE of CALIFORIGA THAT THE <br /> iEi 741 U <br /> MFORMATIM PROVIDED A le TRUE AND CORRECT. '1.11 <br />