Laserfiche WebLink
California Integrated Waste Management Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 <br /> 1E{X1A*JP1L1E1 1112131 ="�C '.o3� i' w Comprehensive Trip Number <br /> S""°'�""" INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE <br /> CIWMs igni gthi <br /> By signing this CA Comprehensive Trip Log and Receipt,the signer(s)request that the Information provided on this Corm will be considered confidential,proprietary and trade secret In accordance with Title,14 CCR,S_ectbn <br /> 17041 at seq.,Its request Is made for disclosure of this Information,the C1WMB will contact the signer(s)of this form at the address and telephone number provided on this form or recelpt. _ <br /> +='�"1=tJiii Lk;,V ehicle Information <br /> Hauler Address' <br /> Truck Decal Number Business Name <br /> Address <br /> City, State and Zip <br /> License Plate Number State <br /> ®�® o �t Ll Carrie�n <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 em t felsdiw6on of IN atio y result in suspension,revocation.or denial of renewal of th <br /> Waste Tire Hauler Registfation pursuant to Public Resources Code section 42960 and may result In civil penalties up to$: per day,per Cation administrative p hies up to ,000 par violation per day as described in Public Resources <br /> Code section 42 <br /> 9 0 7 la 7 12' <br /> �'2.4 <br /> Driver (print) ' Driver Si Hure Date 11 <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> Pick Up Delivery — a <br /> �. 41_ � -- C 0 0000 l <br /> m Hauler Tire Program ID ! x facility Te on er <br /> I: ... W.E Whole Tiire.Count.- viveight I Lbs.cc <br /> ` / - llilifFir) c.4S,/��l�y 'y�l <br /> D Volume-CuBic Yds.C'Weight•in Tons <br /> e ({t�Er iV(1 <br /> �+_•� lV��/.S,- "� �;�Lir'/� <br /> o Ha m <br /> Na - <br /> Hauler Te ///n���e Numb r ■ Address Sal user Initials <br /> ^ �' / / �i' (N/A fOf I CERTIFY THAT UNDER PENALTY OF PERJURY <br /> /\ [/ Whole Tires) LAWS OF THE STATE OF CALIFORNUt THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> "t <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix J <br /> i. . <br /> Q 41516.15 a. 8 Pick Up DeliveryE E,©E 2 a —N/2 <br /> LIN <br /> Hauler Tire Program ID I Site Suffix Facility Telephone Number <br /> DATE ON / <br /> ED <br /> F c Weight{n L•bs. <br /> =' <br /> eo nw. � Whole Tire Count � g <br /> I <br /> E. <br /> (< C Volume Cubic Yds.C Weight in Tons vailielHd �i� l <br /> E iYy, 1 �v`P, <br /> o H��r Name T�'c� DEE' 0E <br /> , �afr�i <br /> 00 <br /> Hauler Telephone.Number ■ Ad'd�ess Satire as Hauler Initials <br /> (N IA for 'I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OG THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> I. <br /> Comprehensive a LogNumber • • Information •• l <br /> Q 4.15:1.6:15. A Pickup ^ Delivery 0 ptifi 9 isid/N <br /> dFacility Telephone Number <br /> L. ,. Hauler Tire Program ID l Site Suffix DATE <br /> _ w Whole Tire count a Weight In.Lbs. a r <br /> i. <br /> C Volume Cubic Yds.C Weight in,Tons <br /> Hau{ Name F4., 7sip <br /> ol? <br /> Hauler Telephone Nu b a ■ L_1 Acldrfess Same as Hauler Initials <br /> (N IA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE 02,b <br /> r/ /t, <br /> 2.�• / Whole Tires) AWS A THE$TATE OF CALIFORNIA THAT THE L n.� <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />