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Ma Y. 29; 2013011 : 11AMv. V --oS er No, 8883 P. 1 <br /> Toll Free:%-A15-896'Q,600 '/.wwwx4nib`,cu iv%Tires/ <br /> r - - - 'Calilornls Irllegraled Waste Management 9oard <br /> CA Comprehensive Trip-Log and- Receipts T000z 6axfTag,baer�manLa,CJi95/,2-,ZSg <br /> f com rehensive:Tri .Number <br /> li■f Edyamfa <br /> ciware:7l(Tt;ttsl INSTRUCTIONS ON'BACK OF PART2 DO NOT PAPE:•STAPLE OA DUPLICATE' <br /> I)y elgnrrg Ihls CA CcmpI.han•1.•TLrp Laq and Recelpt,the elgq+r(.)I.q..elthII 1i,e Infarmallw provided on W.la few will b•eonsld■r•d eonEdentlal,proprietaryand tr.d.a.cnL In accordance wlln T,Oe,14 CCR,Se=m:n <br /> 1104 et eea.;It reouest ls'mads for di.rlo_o_w■of ibis Inrormation,the CIYV8 ,'lI ccr II;llh•6mn.r(:)or this format the 39areaa•ad 1•I•ph ppe nufgbar ptortdcd aRNla form or ayi'FL <br /> Hauler Address <br /> ..©usina's,s Name <br /> (' <br /> Address, - . <br /> City, Stae a6d zip /' <br /> Cgmma� � <br /> C 6. <br /> .� Z I D Garrjtir <br /> I certify under penaiLy of p+,+,rr Wldar NL I:AS of Ne Stale of Cal:/crnla Ihol Ilw Mlom�AC,.i proNOtd■hove 6 Lv�ani co'rnd.rn 0J660 1 am a.vaie Vel tai• dM of dv.Inlorm9fOn m:.y roe:Hl m wspenclon,n�voPl(pgror defd4f 01 rfresr:l of Cr <br /> Waa!e The Haver ReylElra�on pvn;vantroPubgeRsourcec t:ole:^_coon 123J0 and may le6Llltn d`6l peel L•a�p!o t.25,000 pe.Ery,PrrvrA!•Era ore r>G:, Pe In <br /> vp to SS,000 per Jiahton ppr day as rteaen�e'd(n CUFtlic fteeo,vr'ta <br /> Coda sscLon 62gB2 j •'^���"'� <br /> Dnvet's Name rint <br /> of ve Signaturo. Da e <br /> 324870 . C F71 T 0 .0 <br /> HaulerTlre Program ID / Site Suffix Faallity Telephone Number <br /> Fac"Wusiness <br /> NatYl'i4:4ltbrra <br /> Cit t t tXt.l , <br /> Hauler Nama y� . <br /> StEri�L� or� !4v �`G <br /> Hauler'Telephone Number . El-AUdressAe as Hauler <br /> I OERTIF7 THAT WPM PENALTY OF PERJURY OF TNI: <br /> �'`, SJ� /�✓ ^1 LAWS OF THE 6TATCOF CALIF ORNtA THATTHE <br /> Z V\ ( 1 IN FOflL�ATIO;!PRr f.0 A00VE 12 TRUE AND CORRECT.' <br /> ■ 17v MW e ■ 6 e ■ ■ ■ . 1 J <br /> 3248 <br /> Hauler Tire Program lD 1 Site Suffix Facilily.Telophor a Number,., . <br /> z.., Do-DD�DDDDD � <br /> D <br /> Facllit �� <br /> aj <br /> Narne/Adclre�s <br /> Hauler Name <br /> G�llitidt8fcq and Z t <br /> 1k Slaw of4.01l{?K,. �'G�� f,5 <br /> Hauler Telephone Number Address Same'as Hatllet/ 1 rt, <br /> I CERTIFY THAT UNDER PENALTY OF PERJl1RY OF'TN[ i <br /> LAWE OF TtIr SPATE OF CALIFORMIATtIATTNE / <br /> 7 ) IKFO Y-A70N PROVIDED ABOVE I5 TRU <br /> 3248701 <br /> D D0D © D <br /> Hauler Tire Program ID j/ site Suffix Facility Telephone Number . <br /> . : . fi nsH <br /> DDD <br /> -111 ly <br /> Glt',&p 11(1#11 166 1. �• rc( <br /> Haulelt N �}ttf <br /> Hauler Telephone Number Address Same a� Hauler / <br />