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California Integrated Waste Management Board ` <br /> CA Comprehensive Tri Log and Receipts P.O.Box 1259,Saorgnn..W,CA98912-1259 <br /> _ rj7C A P 1 L 3 1 2 Com rehensive Tri Number <br /> INSTRUCTIONS ON BACK OF PART 2 NOT TAPE.STAPLE OR DUPLICAT 3027 <br /> 171 <br /> Bysipping Nis CA Ccmpmhanalw Tdp LOB and RacsiPt W.Mgnwfal—..a1 Mat IM Inf—U-X-Idad on Wis form MII N wnsidsrad—IIII.Mal,W pdatary and trad..stet M accordant.wah TDM,f•CCR.Sa.v- <br /> 17041 at <br /> raauast la=1 for disciosun of this InfaTnetlon,IN CIWMB MW Contact W.alpnar(a)a 11,11 loan a IN eddnas and MMOhons-oaf P,­W"on this loon or rscslpt. - <br /> Truck Decal Number Hauler Address F <br /> Business Name <br /> �_ 1-17 .� _ 0533307.0078 3730 /0•W'z_O 1 <br /> License Plate Number stat <br /> tt .�ate Address <br /> IlCity,State and Zip <br /> I canny uwe'P.n.ilyot PeVaIY under We I—a IN stat,a Csir Wa IN-toren.—pr0vidad aeoYa M Dw.w toner.In addition,I.m.w.ra Wei MWnretiOn a Wa iaom,amn may revue in wspa-ion,ravoralf.n,or denlsl a.-.ad a IN <br /> W.-Tirs Raub'Repntretbn purWaal b PuMk Resource.Cod.-42050 and may rnaua in CM Waite.up W$75,000M day,per v Aasgn m adMNaD.tlw psnsMes up W S5,00D per v Is ,per day aedeaapled In P,k,k Resaurtas <br /> Code settlor 47992 <br /> Driver's a e(print) Driver's Signature Date <br /> Comprehensive Trip .. Number Load InformationProgram <br /> 3027171 -- `' Pick Up 11 Deld <br /> Ll <br /> .Ll 11 U 0 0 0-0 <br /> 0 <br /> D Hauler Tire Program ID ! Site Suffix Facility Telephone Number <br /> DATE a s WholeTtreCount Welght, ORD-OnODOOD <br /> ❑ Facility Business <br /> To.Volume Cubic Yds:❑Weight In Ts <br /> m Name/Address <br /> hCity,State and Zip <br /> Hauler Telephone Number <br /> L) [1■a a Stamp or Label OK. <br /> mluara <br /> Whole Tires Only I CERTIFY THAT UNDER PENALTY Di PERJURY OF THE. <br /> fo(Whole Tl�e Count. .'_.._.___ uW9 OF THE STATE OF CALIFORNIA THAT THE <br /> . -... , INFORMATION Pf1eVIDlDWSOVP/81RIIE' - ;.......ww.•....,...,... :..... <br /> Comprehensive •' Program <br /> 3027171 -- B <br /> N aPick Up �❑a Delivery <br /> Hauler <br /> Hauler Tire Program ID Site Suffix <br /> Facility Telephone aNumber <br /> DATE <br /> aoo-0000000 <br /> c w <br /> E Whole Tire CountHWIS <br /> Weight in Lbs. <br /> i-a Facility Business <br /> Volume Cubic Yda. I ht In Tons..g Name/Address <br /> o City,State and Zip <br /> w Hauler Telephone Number <br /> CJ .❑ �. Stamp or Label OK J <br /> ! Initlels <br /> . Whole Tires Only I Cld n THAT UNDER PENALTY OF,PMURY OF THE - <br /> for Whole Tire Count .LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVDJED ABOVE IS TRUE ANO CORRECT. <br /> Comprehensive <br /> • a• Number Load InformationProgram <br /> 3027171 -- /4 Pick up ' Delivery <br /> Hauler Tire Program ID I Site Suffix Facility Telephone Number <br /> w DATE <br /> Whole The Count Weight In Lbs..12 <br /> A �l <br /> Facility Business <br /> Volume Cubic Yds.F]Weight in Tona w o0Name/Address <br /> w Hauler Telephone Number City,State and Zip <br /> y,�Y1 a a o a a o o Stamp,or Label OK <br /> �'�' • -3 ■ nl leis <br /> Whole Tires Only -1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE I YS <br /> for Whole'.Tire Count INFORMATION PROVIDED AS VE IS TRUE AND CORRECT. +' t <br />