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Toll Free 1-866-896-Q600'-/www.diwmb.ca.gov/Tires/ <br /> California Integrated Waste Management Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA95812-1259 <br /> €X a M P _ Com rehensive Tri Number <br /> IM <br /> w -�-T <br /> ShM er Ca!.h <br /> crnarBx+�(ran1s)INSTRUCTIONS ON BACK OF PART 2� DONOT TAPE,STAPLE OR DUPLICATE <br /> By signing this CA Comprehensive Trip Log and Receipt,the signer(s)request that the Information provided on this form will be considered congdentlal,proprietary and trade secret In auordanco with Title,14 CCR,Section <br /> 17041 at seq.,If a request is made for disclosure of this Information,the CAMS will contact the slgner(s)of this form at the address and telephone number provided on this form orrecelpt <br /> Hauler Address <br /> " <br /> usiress Name l//`)`1, <br /> 13 <br /> " 2 Address ' r'1 ,G 11 30",- <br /> City, State and Zip <br /> Came <br /> 1 cerlify under penalty of perjury under the laps or the State of Cal.omta that M Iteration provided above Is We and correct In aW.Uon,I am snare that falsftj;Qq of this fnforma5on may result M suspenslon,rpv5 bon,or dental of renewal of th i <br /> Waste Toa Hauler Registation pursuant to Pub lc Resources Code section 42960 and may result in 0A penatces up to$25,000 per day,per vroWon or admhds tine na16es up to$$000 per vi0!ation per day as described In PubSa Resources <br /> Coda section 42962 i <br /> Driver's Name(pant) D vet's I�nature, . . Date <br /> . • 1 •a �• • . 1 . . •• r <br /> 3248854 <br /> Q aH/2 <br /> Hauler Tire Program ID 1 Site Suffix acility Telephone Number ao <br /> _ <br /> F , <br /> Fiusinessl <br /> � / ` hdamelAddres,> <br /> 1. <br /> City' State anti Zip <br /> auler Na es' <br /> Stamp or Label t71C <br /> Address Sane as Haule> <br /> Hauler Telephone Number m7nar <br /> I CERrlFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE Or CALIFORNIA THAT THE <br /> � <br /> r1 .J f 9NFORldATH)N PROYIO O= OVE IS_TRUE AND CORRECT. l <br /> 3248854 f <br /> Hau"ler Tire Program ID / Site Suffix Facility Telephone Number <br /> -DOE-HUH o HOE <br /> F7acilify.Business `r <br /> C' NafrielAddress <br /> City, Sttte and7..ip L, <br /> Hauler Name �� TC�1 <br /> IZ <br /> Stamp or,Mabel O1< " <br /> Hauler Telep one Number <br /> Address Same as Hauler Jrfiva%s <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> 'LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> FORMATION PROVIDED ABOVE IS TRUE D G RRE�. <br /> • 1 1 •• 1' a.• a 0 •• 111r <br /> 3248854 <br /> Hauler Tire Program ID ! Site Suffix Facility.Telephone Number <br /> 9 _ <br /> Fatifity business Ti VVI �,OO <br /> .a® NglilelAcldress ` j(� <br /> Hauler Na e GI[ State and Zip <br /> Stamp ur.Label 014 <br /> Hauler Telephone Number U Address Same.as Hauler cr,ruars. <br /> THAJHOER PEIrALTY OF'iURY_Of YFIE ? ; _ <br /> n - , T <br />