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12/30/2014 01 :49 IFAX isacramr @eastbaytire. com Dianne Amaral 2 006/015 <br /> Tull Free 7.1866.896.0600/ www lregycle.Ga.gov/Tire-s--/ <br /> Aa%,,�omprehensive Trip Log and Receipts 10002 P.O.Box 1280,Vedes Smonmento,OA06812-1 <br /> cd - A Comprehensive Tri Number. <br /> - EL <br /> tixpww;,wlNSTR4JCTIONS <br /> ON BACK OF PART go NOT TAPE.STAPLE OR DUPLICATE <br /> By sIg^Ihg Me CA Compmhehefw Trip Log end Reoelpt the■lg^Kh)nnua■t that the lydarmadon pruWd■d on Chia larm rill tw canaldemd aardldanUel,pV*0*I4ry#Ad Rede 4eor44 lh♦0oardaaea with T^la,14 COR,enation <br /> M41 et eet}.I1 "egyeei It Mtde for 0140loeure O1 isle MMOrraaTla^,GIRa0y01a will oonlaol Ih■atpnertat of this rano■t Ma uddrun and talaphane namba"prodded a�Ih4 br.a a nnlp� <br /> Hauler Address <br /> Business Name <br /> Address <br /> City,State and Zip <br /> v Y1 �7 1 <br /> ❑ Common <br /> G �S=Gt i r.,�i�iC�► � � �� �I <br /> Carrier <br /> I oetclly ander 06MIry of perlUrY Under Ih■k"of rht6lele OI 4'PllferYp[hot the Inla tlm pmMao above Is L,m and oonaal.In adtlhlan, am nvary lhat N4Hlca1lon or rob IrAPrmellOv,may n�Uh I^4uaparnloq r�roaatlan,ar denial al mnnwel bf <br /> 4 Wnta The HeuW Repl"W pumuem to Public Naftmee Code OW10n 429W W may nowt N clve panallln up to 444,009 par dry,per al lvn or adminl 4 p4nehlel up,0 0 p■'AV&l-per day n d-odbad M Fubllc Rnaaur— <br /> Oode aactlon 42682 ��� <br /> C. N�& M CC.a!t 44 �2 �/ <br /> Driver's Na a ri �! Driver's Signature Date <br /> e . . Fill ■ <br /> 4847892 - ,-- .0 - <br /> HaulerTire Program ID / 51te'Suffix j1 Facility Telephone Number <br /> V� � IDII I� .. � <br /> [�f <br /> �reU <br /> `+ �yrel a <br /> Hauler Name � artf.i <br /> , P/b <br /> LjHauler TMephbne Number <br /> Address Pamaas Hauler r.,rean <br /> C M OF THAT UN06R PENALTY OP PERJVT.OF THE Y <br /> y� I CC OF THE STATE OF CALfFORHIA THAT THC {�/r <br /> INPORMATION PROVIOW AV0Ve W TRUE AND qQBR rT <br /> i <br /> �n,r u , •x- 7, r t, <br /> /� Q <br /> T V , n't r:,:': <br /> Hauler Tire Program ID / Site'Suffix ...611tyI,.,elephone,Alum or <br /> ALM 1 et 0E <br /> Hauler Name J. ,~ , ;? `�:'Xrr71 •t, � <br /> '" '• - T+F_,.:I .'gi11� M, 1f^.,I -r <br /> Hauler Tel9phtye umber , rntIl.MM� 44 �it�4ra&;Hauler r <br /> /q I N �yB�IYO R.IURY OF THE <br /> VY <br /> ��#m '� A C" aaw THATTHe <br /> ur ,� e e�Hoca <br /> n'y✓q;rtc;.'1:'{�I,e!Ni0 l ['rI°1?`t b ! � o, <br /> 8 4 �nX <br /> NWIN <br /> IMM F, <br /> Hauler Tire Program ID Sitev, (%r cry ill �91i a'Numbar <br /> d,i iresF;tenf IB viPlr, Mitt a n "r a m P Iv <br /> 18 <br /> ,iii f :V;;NYv <br /> 1101- 1 <br /> '7.V <br /> rte", ort 1yry 2. 4't: YITt+C► 1�i :(�dKrrtr,',:r I <br /> Hagler 7el'ep,hone Numbeh <br />