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Califomla Integrated Waste Managetrsil Board <br /> CA Comprehensive Trip Log and Receipts P.O.Box 1259,Sacramento,CA 95912-1259 <br /> E¢X A';M P L E i 2 3 =0Comprehensive Tri Number <br /> INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICAT 3027 <br /> 212 <br /> BY adenine el CA Comprebena-TOP doe and N.,I L—signed.)raeae.I gut Me IMmmaeon provided on this form will be—.1dend c—fidenlel,propdalary and bale secraL M a—dance wIth This,14 CCR,Bectu- <br /> 17a11 at sea.,If a re i...1 Is made for dlaclosun of this Information,the OWNS will canted tm 11 01 Deal dorm M the address and telephone number prmlded m this dorm or receipt <br /> Truck Decal Number Hauler Address F ROMAN GALVAN TIi21E � <br /> ❑ © � ® ❑ <br /> Ij ® S� Business Name pp.Box 78407 <br /> ( 06214070920 Bakersfield,CA 93383 <br /> License Plate Number State Address <br /> 0 © Id 1111,0-. B 0 City,State and Zip (661)397-7756 <br /> I canny under penalty of Md,ry under the laws of tin Stale of Calftmis that the Infornrui pwldad above Is true and correct.In addNcn,I am aware that falsiflranon of this in nenud n may result In suspensim,revoca on«— of nrowal atinall <br /> Waste Tin Hauler Registration Pursuant to Public Resources Cd.lactic.42900 and mat result In-d Penalties up to$25A00 per day.per vkilidd,«adminHtraWe PenaNes up to$5.000 Par OcIati-per day as described In Pubnc Rasoumm <br /> Code wil 42902 <br /> _4,21-1 it✓ (ifiA14/`� <br /> Driver's Name rint) Driver's Signature Date <br /> Comprehensive Trip .. Number Load Information .. s Site Suffix <br /> 3027212 -- C Pick Up ,,Delivery ❑j ® Q w H H H-D i <br /> Hauler Tire Program ID I Site SuffixFacility Telephone Number <br /> DATE ED/ <br /> DD / <br /> D[A <br /> _ 1 C <br /> 0E,P- <br /> c a ❑Whole Tire CountRWelght <br /> Weight In Lbs. <br /> Volume Cubic Yds. [Facility Business .. '. ;I• <br /> m Z /' ❑ In Tons Name/Address �)n <br /> E City,Statg and Zip n`• �' <br /> Hauler Telephone Number C4f%Bi.t(d r•s <br /> �j I. _ y J]EF]L].F] <br /> a Stamp a L bel CAI(OK ,(7(7 IIOc KcJnci C' on fI/M/� / {yam —1 <br /> Whole Tires Only I CERTIFY THAT UNOER PENALTY-FEMIRY OF TX! <br /> IAWa OF THE STATE OF CALIFORNTHAT THE <br /> IA <br /> fo[Whole TJrfl CounL'--------- - INF R FRevtxe .Nets <br /> CO.r , <br /> Comprehensive . Log Number Load Information ..ram Is Site Suffix <br /> a <br /> 3027212 " B '[Pickup §rbelivery a ❑f © a H-0 <br /> mHauler Tire Program ID I Site Suffix DATE Facility Telephone Number <br /> q l's�'Liv <br /> det 1r�� �" 0 �1000-HODHEIM <br /> M a ❑Whole Tire Count Welght In Lbs. M <br /> i- ❑Volume Cubic Yds. Facility Business <br /> S _ S Q Welght In Tons Name/Address <br /> o City,State and Zip <br /> L) Hauler Telephone3Number <br /> f.� Sta or Label OK ` <br /> Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> for Whole Tire Count LAWS OF THE STATE OF CALIFORNIA TNAT THE <br /> INFORMATION%20WOE0 ABOVE IB TRUE ANO CORRECT. <br /> Comprehensive.i a • • • • Program <br /> 302 7?,12- - A Pick Up Pelivery lu LIUMDUH-DE <br /> zHauler 1'ire , ram ID 1 Site Suffix DATE Facility Telephone Number as <br /> Sa a❑Whole The Count �We�ght In LbFacility BusinessVolume Cubic Yds. Weht In Tons <br /> d / p ? � s � I g Name/Address (� �f ►' <br /> E <br /> City,State and Zip. `��� <br /> ;x Hauler Telephone Number �7G(� G )52 C) <br /> P1t,110 <br /> .110 <br /> a a Scamp or Label OK <br /> 7 —1,6 ` Ire/ 4 Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERIURY of THE <br /> for Whole Tire Count OF TITCAFRNA THAT T1111VE <br /> 15TRUE AND CORRECT. <br />