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California Integrated Waste Management Board CA Comprehensive Trip Log and Receipts 10002 R.O.Box,259.Sacramento,CA95B,2-,259 U. IE,x AIM P I!r E 1 2 3 Comprehensive Tri Number � sn.r.orarm,a,a awwnlama(,a�ns)INSTRUCTIONS ON BACK OFPART2 DO NOT TAPE, STAPLE OR DUPLICATE 3737202 By signing thla CA Comprehensive Trip Log and R-1pri,the signer(.)request that the Information provided on this form will be considered confidential,proprietary and trade secret.In ac—danoo with Title,14 CCR,Section 17041 at seq.,if e request Is made for disclosure of this Information,the CrwMB will—b-I ttm signer(,)of this forth at the address and telephone number pm,ldod on thie form or recelpt V,ehlclellntormat on Hauler Address Truck Decal Number 11Q0nO� / �rC — E � ❑ ® Business Name 3 1/1101 Address � 30 /V, City, State and Zip �y �1 LicensePlateNumber StateC4U ek 0 Carrie on L I certify under P.—Ily of perjury tender the laws of tho State of Calif.—that the mfonnstion provided above is true and correct.In addition,1 am aware that falsification of this information may resull in suspension revocation,w denial of renewal of ttr Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 o d may result in civil Penalties up to$25,ODO Per d labon or admmistrabve penalties up par violation per day as doscribed in Publle Resources t v� 00 'ff Code suction 42962 � \ 1 s.� A/�(,�� Gt erg- ; ; P e v ..o� �• /0 Driver's Name(print) Driver's Signature Date CComprehensive Trip on •• Number Load Information Facility Tire ProgramII a 3737202 -- C Pick Up Delivery — ! Hauler Tire Program ID / Site SuffixDATE / / Facility Telephone Number Wei ht in Lbs. ❑ ❑ ❑ ❑❑a ❑ � w Whole Tire Count� � g [—Facility Business t d ~ Volume Cubic Yds. Weight in Tons Name/Address Hauler Name City, State and Zip o ) n Stamp or Label OK j a ■ Address Same as Hauler Initials Hauler Telephone Number � _ ' (N/A fOr I CEFTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole TIre9) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE 19 TRUE AND CORRECT. Comprehensive • •• Number •.• InformationProgram ID .'I I .I a 3737202 -- $ Pickup ZDelivery © [D] ❑ ❑ ® ❑ C� _� © , Hauler Tire Program ID / 'Site Suffix DATE HH�/ 1 O Facility Telephone Number cc C � aoa oa � aoaa LU IAS Whole Tire Count Weight in Lbs. > Facility Business n U I 1 Volume Cubic Yds.❑Weight in Tons Narne/Address E City, State.and Zip o Hauler Name 3 a Stam p or Label OK —1 Hauler Telephone Number ■ M Address Same as Hauler rnrr;rs yJ� (N for I CERTIFY THAT UNDER PENALTY PERJURY THE 1 �C) Whole IO TIrCS) LAWS OF THE,TATE OF CALIFORNIAIMA THAT THE ' I INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. - i Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 3737202 A Pickup D Delivery Facility Telephone Number Hauler Tire Program ID / Site Suffix Fac ' DATE 11 ui Whole Tire Count Weight in Lbs. F lits sines /� i `m 191,31 1 r ❑ Volume Cubic Yds. ❑Weight in Tons /rkdd so. re S�U I S ve- E Hauler NameGt�� \ 675-A06 tj �rci✓1 Gn �f'�e QE O j' Stamp or Label OK Hauler Telephone Number ■ ! Address Same as Hauler rn;ears O / O} �� (N/A fo I CERTIFY THAT UNDER PENALTY NI PERJURY E THE ^ l/J� + fff Whole TIreS)Y• AWS OF THE STATE OF CALIFORNIA THAT THE tVT INFORMATION PROVIDED'ABOVE IS TRUE AND CORRECT. I�