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CalNomis hleegrated Waeaa NIRRagemRln Board <br />CA. Com rehens427 <br />Log and Receipts 10002.. . a,C.BOR1259,SBNXe11NIRto.CA95/,2-1259' <br />E' X A M P L E . ` RIM <br />_ .Com rehensive Trig) Number <br />INSTRUCTIONS ON BACK OF PART 2 `;DO NOT TAPE. STAPLE OR DUPLICATE 37452031.0—wamiffs) <br />. - BY elgning mis CA Co rprMumM Trip Lo=g R -11A. th lon•rl•),•quest UM the Irdannual , PrNd•d a yNN larrrr w01 m tomldereU mnflUsnllel, proprNt•ry sr,d bels asreL'In aomrtlan4 eTtlr TIN, 14 CCR, send-,.. <br />17011 N eery, X a raRrra•t N m•Us fp UNdo•W W Nle Information, Urs CIWMB add sambeat IM'•Igrnw(•) W Rile farm N iM •tldms aI,U bAepbon• nunrbq - <br />ProMd•d a, Nb form ar mcNpL J <br />e e n olTnet on Hauler Address + 1 <br />,fuel( Decal Number Business Name O v4C� • UT 71 (75 <br />Address 13 d^ 5 -SC) U -T IIJ F <br />City, State and Zip I S'v�K N -.9 5.2 06 <br />License Plate Number. State <br />I oaNfy under Penalty of Perjury undm Me laws a1 the Stara of California Net Me Information PmMW .bane Is we and oon l. m addri I •m sera ebt falsification o,e,is tiifnrmelbn may result N suspension. nwutlon, or dmm of renewal of mt <br />Waste T e Hauler Reglat slim Pursuant <br />to Raeoures Code entan 42860 and may result mid! ceerMNle•up to f 25,000 Par day, Par WolaOon a a fere le up to 315,000 per Malatbn Its, day as described in Public Resourtoa •. <br />Cade sedbn 42962 0906207 0 01 i <br />of `�v' oil <br />Driver's are(print) Dr 1gnat Date . <br />3745203 - C Plt;k',Up �rDel�eryj �' D L, asessom <br />Hauler Tire Program ID .1 Site Suffix ` a` Facility Telephone Number <br />DATE" <br />m ❑. <br />oa/ I®��Nao r_ EHEHE.Ho <br />Whole Tire Count Weight•In lbsHED. <br />, facility Business <br />jQ1? t1 114111 7 `{ � � p � � ❑, .Volume Cubic Yds ❑ Welghtan Tons' Name/Address <br />E 1 l` <br />sol Hauler NameCity State and Zip <br />T) F Q O, i Stamp or,L el OK <br />p a ,oa a 00`w:� ol�Y, ❑ Address amens-Han1{"a Hauler Tele hone Number rD ra <br />'•� <br />' y I CERTN7 ER PENALTY OF PERJURY OF THE <br />�' / 1 Gam' µ ' LA THE STATE OF CALIFORNIA THAT THE <br />U . <br />xyu 1 * d r W B�� 81•I ORNATO ROW EOM 0 R T1 E A D CORRECT. Y ' <br />.s+t; <br />• - • Program I/ Site Suffix <br />nn <br />spa 37:45 2 0 3 -- B. Plck'up '� Del <br />� °Hauler Tire Program.ID. / Site ffix DATE / / Facility . elephone. Numbe[ <br />'r <br />W. <br />a� WRoleTireCount -❑,Weight in Lbs,'. ©a <br />Facili Business�� <br />d f D �1 7 �' D ❑, Volume Cubit Yd*. ❑ Weight In Tons ',Na /Address <br />o Hauler Name J C�/ Ity, State and Zip6G�//C�y��(ti/fJ <br />Stamp or Label OKv CrCA /�C' <br />-Hauler Tele one Number U ■ ❑ Address. Same as.Hauler <br />p " '(N /A for 1 CERTIFY TUT UNDER PENALTY OF PERJURY OF TME <br />.. .. - "^C• Who1B TIM) LAWS OF TRE STATE OF CALIFORNIA THAT THE , <br />FORMATION 0 IDEO OVE d TiUE AND CORRECT. <br />comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br />3745203 --A PickU'p . DeliveryV RH <br />R <br />©�Raaaa� 0 <br />1. <br />41 Hauler Tire Program ID / Site Suffix Facility Telephone Number <br />� DATE BTF <br />m UU ❑ WholeTire Count ❑ WeTght in Lbs. <br />t[� Facility Business <br />g`1 �. d' ❑Volume Cubic Yds. l X) Weight In Tons Name/Address. <br />o Hauler Name "'( City, Sl4QLPFNLS.Y PRODUCTS, INC. <br />�- , 13000 NEWPORT RD <br />V o % Stamp or L€BALLIGO, CA 95303 <br />auler Telephone Number 3� Q Addressee► mrXr,. <br />• (N rA for 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br />Whole 11reg) LAWS OF TIIE STATE OF CALIFORNIA THAT THE <br />INFORMATION PROYMED ABOVE 5 TRUE AND CORRECT. . rE �y <br />