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 />
|