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ste CA Comprehensive Trip Log and Receipts 10002 California ox1259,SadWaento,CA95812-Board P.O.Box 1254,Sacramento,CA 95812-1259 EiX AIM P(L E I 1 1 2 3 Com rehensive Tri Number a _. �, � 3 cwms?03(1005)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE By signing this CA Comprehensive Trip Log and Receipt,the signer(s)request that the Information provided on this form will be considered confidential,proprietary and trade secret.In accordance with This,14 CCR,Section 17041 at seq..N a request is made for disclosure of this Information,the CIWMB will contact the signer(s)of this form at the address and telephone number prov lded on this form or receipt �t R�—rn !- 'Yehicle.,infoapationr � v� — —-- —- -- T ..Truck Decal Number Hauler Address ��,y,r o H T 3 1 3 0 Business Name g o wQ c, Address w J ❑ ❑ - a ❑ a a a City, State and Zip S�'o ,�.to License Plate Number State ® 0 ❑ ❑ ❑ -) Carie on _, J I certify under penalty of perjury under the laws of the Stale of California that the information provided above is We and correct.In.eddition.I am aware,�at fats o.'of this information may result in suspension,revocation,or denial of reneval of th Waste Tine Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to$25.000 per day,per violall i' r administrative p—Illes up to$5,000 per violation per day as described in Public Resources Code seclion 42962 v, Driver's Name(print) Driver's Signature Date Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix C Pick Up Delivery 4235708 Ll0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑. Facility Telephone Number d Hauler Tire Program ID .I. Site Suffix DATE Do / ❑❑ / ❑❑ wWhole Tire Count ❑Weight m Lbs. non-❑❑ ❑ ❑ ❑ ❑ ❑ . � a Facilify Busaness ID I I Volume Cubic Yds:❑ Weight in Tons Name/Address E City,State and Zip . o Hauler Name 3 Stamp or Label O! _ v a J Hauler Telephone Number ■ Address Same as Hauler Initials I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tres) LAWS OF THE STATE OF CALIFORNIA THAT THE seesINFORMATON PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 4235708 B Pick Up El Delivery y t f� H-E ❑ EH00 0 Facility Telephone Number Hauler Tire Program ID / Site Suffix .DATE HE ;'HH ; BE c w © Whole Tire Count ❑Weight in Lbs. R a Facility Business i 10 9 Volume Cubic Yds: Weight in Tons NamelAddress i E City,State and Zip o Hauler Name v 1j✓Glnho�+``/ t't a Stamp orLabel©K Hauler Telephone.Number. ■ Address "Same as Hauler rrrsar5 (34, ' (N IA for ICERTIFY THAT UNDER PENALTY OF PERJURY OF THE ' ,`✓ C.. a /^ K q I _ - W N/ Tires) ohms OF THE STATE OF CALIFORNIA THAT THE I•� ]l.� l7 UUUV INFORMATION PROVIDEDABOVEIS TRUE AND CORRECT. L. ComComprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix rel 4 2 3 5 7 0 8 Pick Up ❑ Delivery © © �❑ .® © ®—� a ' Facility Telephone Number Hauler Tire Program ID. !. Site.Suffix U) DATE S �. y t Q ©.—0 0© a ❑ 0 Cc' wa a CountEl in Lbs. FaC : nd .-- (� r . � G) l Q I .9 '� Q t tome Cubic Yds.❑Weight in Tons NamelAddress E Ci 4VAan-i o Hauler Name , 3 t F SI vtG�r►hOv� i r Stamp u.r Labe •. • . OK ,� Address Same a5 Hauler I.Hauler Telephone NumberDInitials .I (N IA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE ZQ U C / LC L'B'WS OF THE STATE OF CALIFORNIA THAT THE L Whole Tires) r) .INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.