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Callfm111a Integrated Waste Management Board CA Comprehensive Trip Log and Receipts .10002 P.O.BDx1259.Sacmmwt*,CA95812-1269 E X,A. M h:7 L 1 C { F 2{3 Comprehensive Tri Number aN2mm ovINSTRUCTIONS ON BACK OF PART 2 'DO-NOT TAPE,STAPLE OR DUPLICATE 38401 O 4 'BT signing Orb CA Com;wwh-ulrs Tdp Log and Re IM#w Nprw(a)n�rast God Om brfonnaUon provmw on Orb form won be corwldwed conRdurft%propd twy wW trade secret In acrro larice w10N Title.14 CCfL Bscson -- 17011 at ep.;M a rgr»•t Is me&for dFeclosu of this bdomutlan.the CrNM will contact the signer(.)of this form at the edGass and telephone nrmrbw prwAdsd on t1W facts or reutpV -• ehic a In orma on Hauler Address Truck Decal Number Business Name AddF11 _ ess TRI-C P�iANUFAC'�'URING7 INC. M P © H . ff Cyr State and Zip TIRE 112 HARBOR BLVD. - License Plate Number State 512 HARBOR BLVD. j WEST SACRAMENTO,CA 95691 ® � ® � 19 © ® ® ❑ Car Common I certify under penalty of Pequry under the Iowa of the State of California that the information provided above is true and correct.In addition,I aware that fasRca6on of This information may result in suspension,revocation,or denial of renewal of Ih - Waste Tire Hauler Regi batlon purwanl to Public Resources Code section 42960 and may result in civil penalties up to$25,000 ped8ay,per i I2UbmoredminiWafi eYA�al6es up to$5,000 per violation per day as described in Public Resources Code section 42962 _"'� e_O .1224 —_2_3--1U Driver's Name print) Driver's Signature Date • • • • • • • . . • • . . 1 ., LL 38-4-0104 -- C Pick Up ❑ Delivery ❑ ❑ ❑ ❑ ❑ ❑ ❑—❑ ❑ Hauler,TireProgram ID / Site Suffix Facility Telephone Number DATE ❑❑ / ❑❑ / ❑❑w E] Whole Tire Count Weight In Lbs. ❑-❑ HUE--0 ❑ Fcilitj pusi"eA E, Volume Cubic Yds.OWeight In.Tons Name/Address E City,'State'znd Zip o Hauler Name ` Stamp or Label OK Andress Same as Hauler Hauler Telephone`Rumb 1 J ■ ❑ Mro e (N IA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE ✓ Whole nom) LANES OF THE STATE OF CALIFORNIA THAT THE IIffORYATION PROVIDED ABOVE 13 TRUE AND CORRECT. . • • • • • • - • s • • •• 1 Site Suffix a X3'8 4`0)10'4,. -- B :. Pick Up Delivery I Vim. ,Jl � - � I "" Facility Telephone Number Hauler TireProgram ID / Site Suffix DATE ase•. -Whole Tire Count Weight in Lbs. IcacTRI-C[MANUFACTURING CO.,INC. `m I ❑ Volume Cubic Yds. Weight in Tons .Na¢nQ%(�'L¢idT/rB.Recycling DIViSi0�1 E ., NC, 'Cltjf,State 6n524aHarbor 111vd� . l H Hauler>damf�i�Recycling Division West Sacramento',,�A 95691 524 Harbor Blvd. OPONM Stamp or Label OFT — — IN a ■ E] Address S m®aS Hau lW H lerT to non n U� T r ; (N IA for- I CERTIFY 41,7,UNDER PENALTY OF PEILURY OF THE , 1 Whole Tires) tAVY8 OF THE STATE'OF CALIFORNIA'THAT THE C.) �•W -1 n&ORMATN)N k&ADED ABOVE 18 TRUE AND CORRECT. Comprehensive Trip Log Number Load Information • • 1 Site SuffixI I• `- I o. 3840104 -- A. [/Pick Up Delivery E I US]. 0 W',M� a d Tire Program ID I Site Suffix - Facility Tolephone�Numtier(j• Hauler l DATE ❑ILI © � ®® / 101 ,s Whole Tire Count ❑Weight In Lbs. Li TRI-C MANUFACTURING CO. t�aciiity[ uslneas ►Sec/G m n olipg.Di 9/ n Volume Cubic Yds. E]Weightin Tons Name/Address C� Ei City,State and Zip Hauler Ria a t Sacramento,CA V1�ss9 Si@m o"r Label OIC Hi ler Telephone.Number li- ODOEKmE ❑ Address Same as Hauler ts r ` t - I CHt74EN Y THAT UNDER PENALTY OF PERJURY OF THE (N/A for ' . Who f rea) LAWS OF THE STATE OF CALFORNIA THAT THE ORYATION PROVIDEDA 19 TRUE AMD CORRECT.