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California Integrated Waste Management Board CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 AJM P (. E. i .2 3 Comprehensive Tri Number E X . riwAf°emirt oosj INSTRUCTIONS ON BACK OF PART 2. DO NOT TAPE; STAPLE OR DUPLICATE 3248375 By signing this CA Comprehensive Trip Log and Receipt,the signera)request that the Information provided on this forth will be considered confidential,proprietary and trade secret In accordance with Tide,14 LCR Section 17041 at seq.,If a request Is made for disclosure of this Information,the CMWM8 will contact the signer(s)o/this form at the address and telephone number provided on this forth or receipt Vehicle Information Truck Decal Number Hauler Address Business Name Address y t/d City, State and Zip License Plate Number State ® ❑ � a ❑ ❑ ❑ UP Pti� a�Common f❑ L-- Carrier I certify under penalty of perjury under the laws of the State of Califomia that the information provided above is We and correct.In addition.1 am awareaptalsifcabon of this information may resuh in suspension,revocation,or denial of renewal of th Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in Civil penalties up to S 25,000 per day.per viol.' a U 'va penalties up to$5.000 per violation per day as described in Public Resources code section 42962 Driver's Name(print) D vet's Signature D to Comprehensive • .. Program t 7Hauler 4 8 3 7 5., __' ti, Pick UP Delivery 0 © D HIM-® M Tire Program ;Site`Suffix Facility Telephone Number DATE to Q, , 000 000a ❑ ❑ o w Whole Tire Count Weight In Lbs. i t } F ilit Business I d• O � . U ~ Volume Cubic Yds. Weight in.Tons - `Lr o Hauler N e t, fa/19M 1i)I2t Vic U I in 1 S p or LabTT0l OK 9 S3 S Q Address Same as Hauler Hauler Telephone Number ■ Initials CERTIFY THAT UNDER PENALTY OF PERJURY OF THE ( NIA for I tAWS OF TNSTATE OF CALIFORNIA THAT THE Whole Tires INFORMATIONN PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 32:483-75 H Pick Up ❑ Delivery Hauler Tire Program ID / Site Suffix Facility Tele hone.Number DATE �a � y p I.�V\ Weight in Lbs. ©.'� ® a❑ H H HE Lu ® Whole Tire Count ❑ g Facsinr©1� �5`� _t;�;F!` 6. Gr ( El Volume Cubic Yds. Weight in Tons res E o Hauler ame U) t N S ! . 0� 1 Hautes Telephone Number 1 El Address Same as Hauler ;millets .. `�)1 ]� ,`..^ (NIA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE 1�'S 5 .iI nt 7( ) ) _ Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE O V v ..!// ((( INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 3 2 4 8 3:7:5 �- .A Pick Up ' Delivery ❑ ❑ ❑ ❑.❑ ❑❑-.❑. iv _ Hauler T' Program ID I Site Suffix Facility,Telephone Number. � DATE o.aa-ooao y o0 to 1/ Ui M Whole Tire Count 11 Weight m Lbs. Fact I �� /� y ,• 5. f� ❑Volume Cubic Yds. O Weight in.Tons Naz ) red I`- !I E Hauler Na , " CitiO �r(�ZipL if E] Address Same as Hauler Hauler T ephone N er ■ Inlflats , 7 I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE (NIAfor ot LAWS OF THE STATE OF CALIFORNIA THAT THE Whole-Tires)IA f r 444 _/ I INFORMATION PROVIDED A80VE IS TRUE AND CORRECT.