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California Integrated Waste Management Board CA Comprehensive Trip Log and Receipts 10002. P.O.Boa 1259,Sacramento,CA 95812-1259 E x AIMP I L .E� 1 2 3 Com rehensive Tri Number so'aGr,�a,. 3248372 cIWMe20d(10105)INSTRUCTIONS ON BACK OF PART-2 DO NOT TAPE,STAPLE OR.DUPLICATE By slgning this CA Comprehensive Trip Log and Recsipl,the slgnerls)request that the Information provided on this form will be considered confidential,proprietary and trade secret.In accordance with Tiae,14 CCR,Section 11041 el seq.,if a request Is made for dlsclosure o1 this Info—rill—,the CIWMB will contact the sign-151 of This form al the addross and telephone number provided on this form or receipt. EVERicle Information Hauler Address r Truck Decal Number ��9/I f- �•'1�J%1,04 i i-C IL-14 �'/'A, Business Name / Address � City, State and Zip y� License Plate Number State Common [.c�e "J Ca I«pity under penalty of perjury under the laws of the State of California thafthe Information provided above is We and correct.In addition,I am aware that falsification of this information may result in suspension,revocation,or denial of renewal of th Waste-Tim Hauler RegistmCon pursuant to Public Resources Code section 42960 and may result in civil penalties up to E 25,000 per day,per violation m a e ve penalties up to$5,000 per violation per day as described in Public Resources Coda section 42962 '- Gt,�ss�.�✓ oo� - Driver's Name print rife;.Signature D e iComprehensive Trip . . Number Load Information Facility Tire Program Q 32448372 -- C C Pick Up El Delivery EEEH ® MN_ o a _ d Hauler Tire PiograiTi ID 1 Site Suffix Facility Telephone Number � DATE ooa-Boa © aaa w ® Whole Tire Count Weight m Lbs. (� f- -- oail,63 t. ioid 1:1 Volume Cubic Yds.❑Weight in Tons N m k,. s t E �e an iP\uONe $ Hauler ame y r �r ci Q N St*- I e O C 17_V� I Hauler Telephone Number ■ Address Same as Hauler Initials CERTIFY THAT UNDER PENALTY OF PERJURY OF THE (N IA for Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE S TRUE AND CORRECT. J Comprehensive Trip Log Number Load information Facility Tire Program ID Site Suffix .I comprel 3248372 -- B Pick Up Delivery a a o o N o PE Hauler Tire.Program ID / Site SuffixrAOTE © Facility Telephone Number 1' bill ®a a© CD Weight in Lbs. R Whole Tire Count g .C3�Al `m 3 b { Volume Cubic Yds.❑Weight in Tons NaoHauler ameCi� rfip or LabelOK _ . HaulerTelephone Number ■ Q Address Same as'Hauler Init;.ls' �''��}}��s (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE OIA THAT THE �` 5 V < Whole Tires) INFORMATION PROVIDED ABOVE SLAWS OF THE STATE OF NTRU AND CORRECT. 1+ Comprehensive ��V VVVV • •• • • • Information •• - . 4 8 3 72 A Pick Up ] Delivery 101H 0 0 D c - •d Hauler Tire Program ID / Site Suffix Facility Telephone Number .. DATE �© �-..fl© / I = o Weight in Lbs. wa ®.Whole Tire Count g —Fa it 'ecss Cubic Yds. Weight in Tons I N e rPss ' E Ca ��i�1i c��l�t-Aarnr i o Hauler:N e H /\ `� � �3U f V N. St mp or L el O ` a ] Address Same as Hauler Hauler Telephone Number - ■ �- U �� r LS / (N IA for I CERTIFY THAT UNDER PENALTY OF PERJURY THE s) LAWS OF THE STATE OF CALIFORNIA THAT THEE Whole Tire /J /Y INFORMATION PROVIDED ABOVE IS RUE AND CORRECT.