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i <br /> i <br /> JI Toll Frt a l4166=896=0600 /mm.civil, a. /Tires/ <br /> i Cautomla Integrated Waldo Management 80ard <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.BOX 1259•SaOram•rao,CA.812-1259 <br /> � �irsaar: <br /> E M p j. 3 Com r'ehensive Trip Number <br /> GwHeioa r(�rosi INSTRUCTIONS ON BACK OF PART 2 DONST TAPE, STAPLE OR DUPLICATE <br /> By Upnlna this CA Canprsh4tulve Trtp Lop.ed a.oeiP,,the Npner(e)request that the InformAtion pro.Ld.d ae thle 4—will b.wneldered confidential,proprletery and trade»wet.1..acce,drnu whh Titl.,14 CCR,Section <br /> 17041 et seq.,It e request le made for dleoiofurr of thia I„bn...nen,m.CIWMB will contsot the alpn rr(s)of this form at ntr addriiii- t h,pnanT nump.r Prewlded c thle tenth 01,reoshaL <br /> Hauler Address INLAND INDUSTRIAL <br /> Business Name TIRE NOR'T'H,INC. <br /> t c d.Ire s 30900 San Antonio St. <br /> i ate and Zip" Hayward, CA 94544 <br /> Common (5 10)429-2999 <br /> I halt IIT under Welty of P6 9-Y upper It a lawe o1 the Slate of California that the Intorma0on provided 6156VA le true and correct.In addl jOc em hues Y tip fagNicst on of this nk met on may ryeult In auepenabn,revocation,w depict of efMslal a <br /> Wats Tiro Hnular Ra0laeatl6n puragant b Public Reaouroes Coda NctiOr,42960 and may result In olvil pan.lpea up to$21S,000 'day,pnr 1460 Or admihietrabve penalbae p to 56,00�pdt,vlolatlon per day•n t7encrlEntl in public Resourma <br /> Coca seoaon 42062 <br /> Driver's.Name rfP!I r ver'* gnature Date <br /> 42 -- C <br /> Hauler Tire Program ID / ix `'t Facility Telephone,Number <br /> J <br /> IacM4, Business <br /> Name/Address 1��') <br /> Hauler Name 't ,State and-7— <br /> 'T Stamp or L C� ` <br /> Hauler Telephone Number <br /> ❑ Address Same a } ._ <br /> 1 r✓�'y+-y,.,` 1 CEAYmV THAT UNDER PENALTY of PMURY OF THE <br /> i LAWS OF THE STATE <br /> OF CALIPORNiA THAT THE <br /> • • N IDED:AEOVEIWWFRUE AM CORRECT. +, <br /> a <br /> 3485542 <br /> i Hauler Tire Program ID / Site SUNix Facility TQne Nurn er <br /> Q F/ <br /> P/ HE REO <br /> Waaler Nt3mg <br /> Hauler Telephone Nutnber <br /> Address Same as hauler <br /> !Hair <br /> I �h [fit �'�*CERTIFY THAT UHDele PENALTY OF PERJURY OF THX <br /> cf '._;LAMS 9FIME SPATE OF CM1FORxtA THAT THR 1 <br /> RMATIOx QVIC149 ABOV 18 P-Y±-AMCORR <br /> • • •• •. <br /> r • Y 0 <br /> . <br /> 2 -- <br /> A <br /> Mauler � ® ®� <br /> Tire Program ID / Site Facility Telephone Number <br /> RODE <br /> 3 t1 `1 FaCll!ty SuSli1PS97—b <br /> ddre65 �4 <br /> `Hauler Name City, SteGn <br /> >� <br /> Staftnp or Lab OK <br /> Hauler Telephone Number n ,A ,, _ ,;.. 1 1. <br /> E0 39dd JN00 d0 9d3-N00 5ZLVGVZ60Z T5 :L0 800Z/OT/OT <br />