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Calllorrile Integrated waste Management Board <br /> CA Comprehensive Trip Log and Receipts 10002 P:o.ei�A,269.8xrarnertte.CA968f:-izse <br /> h X:R l:f.` l (� i 2.j Comprehensive Tri Number' <br /> � -- .3986054 .. . <br /> INSTRUCTIONS ON BACK OF PART 2 DO NOT'TAPE,STAPLE�OR DUPLICATE " . <br /> '.:.. .By aligning this CA Comprafw ltwa Trip Loa and Recalp4 the slaner(a)requrt tlal the lift.. "provided on"form M9 be conaldarad conMenlK preprMbary aM J. <br /> trWa eaerst'M aeeoNana adM TRy t!CCR Section:- <br /> -41M411 at seq.,B a rqueet br made for dlecloatea er tlds bdomeador4 the CFWWB wlA coreaet Bla slgrwls)or this form ra tha adman ane dfaphorr manbW provided on ad.form or <br /> ehicle In rTnatlon - <br /> r Truck DecaLNumber Hauler Address {�f <br /> Business Name. �� a incl Tire <br /> — ®. Address1 o ETE 730 <br /> - :City; State and Zip.. �.._.. . - ,rte I <br /> License Plate Number - State <br /> H `'2 C Corn mcn.. 5+0�� nnf �:: �52�� <br /> 9 Id E 1 M . H E .a Carrier.. - <br /> 1 certify under penalty of perjury under the laws of the Stets o1 California that the information provided above is true and correct.In addition,1 am swam that fakirs®' of this information may result in suspension;revocation.or denial of renevral of th <br /> Walde Tire Hauler Registration pursuant to <br /> Public Resource CMe s:!o 12960 and may result <br /> tiin civil <br /> `p+enal ies up to S 25,000 per day,-per Wa tion or adminis penalties u0 to$5,000,^ar viols5on Per day as dcxtbed In Public R�rurces. <br /> Code section 12962 J uv'I c/ �t/�2 G L L d Q i v 1_ 4 . <br /> to <br /> DrivOeS Name(print . -D is Sf Date <br /> Comprehensive Trip . . Number Load Information Facility Tire Program <br /> k Picp Delivery: -� <br /> _ 39.86054 . U ❑ � 00 � 00L� <br /> Hauler Tire-Program-ID / Site Suffix- ' � <br /> Facility Telephone Number. <br /> � - DATE: <br /> orae <br /> w w E 0 Whole Tire Count Welght In-Lbs, <br /> � - �Gi$ity SuslnQss- .. <br /> Volume Cubic Yds.E]Weight In Tons tiame/�ddr�ss <br /> - City;state acid*Zip <br /> o Hauler Name . <br /> Sta�atp or Label Oil <br /> Hauler Telephone Number. ■, Address Same as Hauler Jam' <br /> (N/A Tor ED <br /> I CERTFY T"T tA�PENALTY OF PERAW OF T)0° <br /> Who/ Thea) LANA OF THE STATE OF CALFORIGA THAT THE ' <br /> ��•, - ABOVE m TRUE <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 3 9�8 6 0:"5:4 ---"8 _Pick Up � Delivery. "H R H OR R 11n .B <br /> o Facility.Telephone Number . <br /> - � HaulerTlre Program ID•./".Site Suffix ED <br /> 3 <br /> o: DATE _ HE-HOE <br /> 3. <br /> g-whoee <br /> Tirecount. E]Welght In Lbs. <br /> f Fpa: y1 0 VoluCubic Yds: Weigh!in Tons ASamelAddre§sE (7 0City,'Stage tiiid�'ip'I :t: , i <br /> g Hauler Name <br /> U lrCinn n Ti f 2 _ (,, O Stamp oeLabel M '1 <br /> Hauler Telephone Number <br /> ■ Q Address Same as;Hauler <br /> . G - (N/A for I bertsY THAT UNM PENALTY OF PER"ry OP TIN <br /> whole Innes) OF lilE STATE OF.CAUFORMA THAT THE _ <br /> O 0 TRl1E ANo <br /> CORRECT. i <br /> Comprehensive Trip . . Number Load Information Facility Tire ProgramJ <br /> .3.9 8 6 0.5 4 : � A 11 <br /> y Pick Up.: a,Delivery a [A'NOaU_ <br /> �. Facility:Telephohe Number <br /> Hauler ID / Site Suffix <br /> DATE <br /> .r..- � : . : .._ . ". . , ago © - <br /> w ` Whole Tire Count Wei:ht:n Lbs. c4 (� t�a�a A(? SbA S <br /> 2I r El Volume Cubic Yds: Welht n TonsCQ t- <br /> p r , <br /> E CIQ�fs �a 0.d-Zip. <br /> � <br /> o Hauler Name I i <br /> e,A �5 Z (� <br /> V c.n n I Ire 6 S4arrat <br /> a o Address Same.as hauler <br /> Hauler Telephone Number ■ <br /> N JA for 1 CERTIFY TN11T Lamm PEPmTy a PERJURY OF TIGE <br /> ( LAMB OF TIN STATE OF CAUFABWE It IOA THAT T}C <br /> _ Wh019 nrea) W TIOII PROVIp®A t8 TRUE AND CORRECT.' <br />