|
12/30/2014 01 :51 IFAX isacramE @eastbaytire. com Dianne Amaral IA 014/015
<br /> Tall Free 1-866-896-0600 / sire c .ca. v/Ti s/
<br /> o•pt,Qf Resources Recyallnp and RepoyarY
<br /> C'orrtprehensive Trip Log and Receipts 10002 go.Box 1249,8sorameMo,CA9fi812-1269
<br /> Com rehensive Tri Number
<br /> 9911 �• {{��,���pp`` E X a M P L E 1 3
<br /> 61ePo41CN' T cc ••
<br /> QUPLIQATE
<br /> encxreaasnna►INSTRUCTIONS ON BACK OF PART 2 D T
<br /> By elgnimig P11.CA 00""W—ds TMP 4eC end R.wIPt 1M Na,1eAe1 r.qu..t dw Me'nfonn�dOn luavlded on lhle Tenn wlfl b•417ndd.r•tl Oe1111deMUl,Proprletery.r,a lrede swat In.wa�dr+e•with TI14.14 CCR,Beetten
<br /> 17D11 el"q,11■nR>+e�t Ie reed,,for dl101Oeun of Ih'.Wmrnadon,0}IRwyol.rPl mn4ot tfl••1 lurl.l 01 MI110rm at Ih••et►ew end l iephoro nuTMr Ornyldep ve7%i.form fx r•OeIPt•
<br /> Hauler Address
<br /> Business Name �Cist I�iny Tire Company
<br /> Address ry fl�fltin tUn Dr
<br /> . 1 ,
<br /> b a' City, State and zip V�
<br /> r /�
<br /> `1 Gommon f Qirfiel J� CA 9453 _j
<br /> x n Carrier _
<br /> I certify onO.r p.nelty al pe"under 1119 Lowe Df 11N 9Wf of CallfernlY 1.1 n•4�D filen pn'10601 1,1 o�'I p.na1111 6 p 10 6 d,o00 P.rIEsY.Per vi0hM0"°r ed'11k11BIrWrwlpmaltlM UP lu 16,000 P.r V'016Nnerwal 0(
<br /> n p� + dt68orlpAtl In P0darlo1 6/COf eRnouraes
<br /> Iro Wee1.Tim Hauler R.glNrtllen pu—an%10 Fuhllc RNWmw CDde see1 P1eY
<br /> CDtle
<br /> :g�
<br /> DrlVer"e SI n@Wre Dmte
<br /> s Name Clot
<br /> -n ID SitC SLIttiXFacility Tire Prograisivo Trip Log Number Load
<br /> Cornprelien
<br /> 9pl'i
<br /> Kllur a466
<br /> 09Facility
<br /> Telephone Number
<br /> Hauler lire Program 10 Site Suffix
<br /> "iff,
<br /> J
<br /> w ®�aoa
<br /> company
<br /> 'P
<br /> 6 �J i'aid iei AriW7 TAC) Harris fAve�-ynuQ p
<br /> V V• t!• V r.w. °r y. ,is, " '+M. I`.{V.\. �c�l,` '3C'j z' �t0 `M yU�G7
<br /> Hauler Name �` ":' - 0Cr' 40 r
<br /> ��/ �• � � I :,,� �' ' 9t',•i})•_�` x.,.;11 =`: +.)F�
<br /> Addresa Game'as Hauler
<br /> ifs Hauls r Terpti�ofyle Num bey 1f Iii.,•lat�F y�l:,ns .�,ir iSC r .�•'WTr i�'FGf•Y'.:r%i%r ry,w' IGER7lF1'TNAT UNDER PENALTY OP PefEfT�'EFTHE
<br /> IAORMCie ATriESTATeOPCAUFORNOW19IS ArM4 ( f
<br /> N�h Lf* L/Y rV� / h t� ,�^,��� ��v�•.'��: '.f,F ,.�rA �� INFORMATT PR DED A90VQ TOLE AND CORRECT,
<br /> .(IE
<br /> T
<br /> HaulerTlre:program.ID ./ SlteSuffix nn' 7'P 1' .' .
<br /> .4' :@
<br /> rs�Sidlu I?" k.�+ "I .;• i
<br /> g r, r
<br /> .4lf iii• 1 .73 �-1• r t� y � {.� I.I!•c�.� .�d
<br /> Hauler Name o S f7':? O� Tr.rl ;y yt of 1�/'�)Llip?�y1 !'y
<br /> 14
<br /> r!i�
<br /> Hauler Tel umber r', Ap, ss,, a�na.as,NaulerW.
<br /> Ind !tr t + n OF7I
<br /> IA�+ERJUITY OF Tr1e
<br /> j1. Irl tr A e F TWAT THE
<br /> D• Wilift
<br /> —
<br /> •
<br /> 4; :=:���9 � --._/`�►, - ray �°,��,a� ;c� � �. � � �
<br /> Q�x II FYI eAljmber
<br /> Hauler The Pro'gtam IID /V I�fe Sitfflx
<br /> ry ., ., ,�`.' �. !—'' a• _ 1 '"51 .1,)"11.. .. �'r
<br /> Hauler%M''4 Aurer
<br /> �,.
<br /> :,'•'iSfk"1 t�1 �a1,r�•i�zlq�3'4c>,.!`ti;r'! t;.'31'SC; �; ��;C.Z; 'tl r. '1 � I9 11� 'lt1 �lC*52.:,"}-� .E' ..
<br /> Hau er T111>lphonl� u r ^�! '
<br />
|