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Calhfom)a InteFul ad Waste Management Board <br /> CA Comprehensive Trip Log and�Receipts 10002: P.O.Box 1259,Sacrament9,CA96812=1269 . <br /> 1: X E A M'P_ L_C C i 2 3. - Comprehensive Tri Number. <br /> MM <br /> INSTRUCTIONS ON BACK OF.PART 2 DO NOT TAPE STAPLE OR DUPLICATE 39896-07 <br /> By signing this CA CumpreMrohre Trip lap end Recalpit, aligner(s)afr(s)request that on IrdortnWon provided on this fams will a <br /> be cone cdldsrdlal.proprietary and fns secret-In accordance sign 11tH,14 CCR.Section - <br /> 17M7 st ss4;It a request is roads for disclosure of fhb adornu ion,an CIMIMB will corded the signer(s)of the form at the address and telephone number provldW on this form or receipt . <br /> Vehtcle7lnforinatton Hauler Address <br /> Truckyy� LJ <br /> Truck Decal Number Business Name' '.�/ / 1 � /T K <br /> a - .. . Address I <br /> O O / City, State and Zip.: <br /> License Plate Number State <br /> ® a 1j,H .® �. Carrier !, <br /> ..t certify uncler 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 result in suspension,revocation•or denial of renewal of th <br /> .Waste Tire Hauler Registration pursuant to Public Resources Code section 42960'and may result in civil penalties up to E 25 OOO per day,per violation or administraWe penalties up to 55.000 r.violation per day as describe Id in,Pubtic Resources <br /> Code section 42962- / _ <br /> Driver'§Name print Driver's Signet re Date <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> a <br /> 398960T-7 <br /> C. Pick Up Delivery <br /> 0 0 000a <br /> o HCauler Tire Program,ID 1 Site Suffix Facility Telephone Number _ <br /> f ;;; DATE <br /> . � ._ . - - 000-ooa000a <br /> � a E] Whole Tire Count E]Weight in Lbs. <br /> �cility b.usiness.. <br /> m El Volume Cubic Yd Weight in Tons ' Nr melAddress <br /> E City,State 4rtd Vp <br /> S ,Hauler Name <br /> ci Stamp or Label OK <br /> a' ❑"'Address Same as Haufer <br /> Hauler Telephone Number <br /> (N/A for I CERTWY THAT WMEIR PI3UILTY OF PER.1t1RY OF THE <br /> . <br /> WholeTia) lwWB OF TME <br /> STATE OF CALff�R1aA THAT E <br /> . Dff010111T1011 pR01/mm ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> p .i <br /> Co <br /> �iI'3`-989`61 . B Pick Up Delivery Hauler Tire PrograiD !. Site Suffix Facility.Telephone Number, <br /> DATE <br /> ctu <br /> Lua Whole Tire Count Weight In Lbs.El <br /> 19 -IS1me Cubic Yds. Welght In Tons '' !tfe" reas � <br /> ECi a <br /> Hauler•Name <br /> Hauler-Telephone Number• `� �' ■ Ail dress Same as Hauler <br /> - ` (N/A for' I CMTDY TWIT UNOER PB ALTY of PIM.M,AY of TIS'. <br /> Whole TIM) LAWS OF TIE STATE OF CALW*RfDA THAT THE <br /> `/ <br /> �n!..r .(: 1 UQ� IMFORYATON PROVIDED AB IS TRUEAND CORRECT. ••/ ' <br /> Comprehensive . Log Number Load Information Facility Tire Program <br /> 39:8:9607 =- A Pick up _Delivery <br /> Hauler'Tlre Program I.D ./'.Site Suffix Ficility,`Telephor�e Number <br /> DATE ®D �ez <br /> Lu E]Whole TireCount -Weight in Lbs.' fac. <br /> ® <br /> 40S-1251 a 4 .16 Iurrie Cubic Yds.a Welght In Tonsi NaiA -Aouea3 �!- <br /> g .Hauler.Name Ci a�'u i _C o;7s <br /> Hauler Telephone Number . _ < J ■ Address Same as.Hauler meas <br /> t ^1 . (N IA' -I GERia'Y THAT UNDER P&ALTr t>F PEiiJURY OF'THE . <br /> Whole arae) uwe OF THE STATE of CALIFORNIA THAT THE <br /> �.INFORWITION PaovlDm ABOVE is TRUE AND CORRECT. . <br />