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cBlitomlB lMagrated waste Managament Board <br /> CA Comprehensive Trip Log and Receipts 0002 P.U.Sox 1259,Sacrnnento,CA 958/2-1259 <br /> E X R M P L E 1 2 3 —� Com rehensive TripNumber. <br /> .3561298 <br /> C�W E 3(1aq INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE � <br /> . <br /> By Jgning NW CA Compmh—d-TOP Lop and RevOM BN•Igmr(a)niq~Wei the mfomuUon W,A an MI,l.,m.11 Oa mmlMnW.onfl—Pal,p,opM.,and Rods wcrlL In aox am•Mlal Tlaa,14 CCK S•etlon <br /> 11011 fl Ip.,H•r.puM u In•M Im Jselwure W NI•MlaDnatlan,tlY CIWMB will o.nfM IM Jpmrlal of NI•farm J IM Iddre•a IrM blsplw,la numear proNdad on tM11o,m a rWipt <br /> INNION <br /> VehiblellhforrKadon Hauler Address <br /> Truck Decal Number Gutierrez Tire <br /> Business Name <br /> Address 919 N. Wilson Way <br /> license Plate Number State City,,State and Zip Stockton. CA 95205. <br /> I (209)462-2024 , I <br /> CCom <br /> arrie on L� . J <br /> 1 wnifr ands,pemlry 0 perjury under Ne laws of Ne stela PI Ca4lanla Nal Ne 1--on p, 1—.lore N true and mnecf.In addlopn,I vn aware Nef hbMutlon of Nlf BlbmYllon may reJ,lt In iulp•n•an,nwcalbn,or denial of renewal d eR <br /> W.I.Ne HauYr RnI. Wn p--to Pudic Rea ,Coo.—42950 and may re•uR In Wil p—Ra.up to E 25.0W Per day,par NOlai+dl or W.Irm onfire parWtle•W to 55.000 per Ndetlon per dry u d..AO d N PVNk Roo— <br /> C'_ <br /> 42852 <br /> /1'� 8 0 0 3 01 J 5 i��j> /� ��o�i>•'Od� <br /> Driver's Name(pi[Kt)* Driver's Signature Date <br /> NumberComprehensive Trip Log , Site Suffix <br /> 3 5612 9 8� -� (►` Pick uP ❑,Delivery; DODO❑ ❑ ❑` <br /> Hauler Tire Program ID /I Site-Suffix- Facility Telephone Number. .: <br /> DATE ❑❑/. ❑❑ /.❑❑ r _ 3; r: <br /> wa Whole Tire Count Weight in Lbs. ❑ ❑ <br /> [F.CIriSG rrez Tire <br /> ° <br /> Volume Cubic Yds. Weight In Tons - Name/.':El ❑ g J19 N. it 'Way <br /> E <br /> Hauler Name City,SS{ockd ZiD, 95205 <br /> U a <br /> OR000EE Stamp Same as H <br /> Hauler Telephone Number ■ ❑ Address Same as Hauler Initial. <br /> 1A for I CEIM"THAT UliOU PENALTY OF PERJIXIY OF THE <br /> Who TUIa). IAWS OF TRE STATE OF CALIFORIOA MAY TRE <br /> IN YATIOH PROVIDEO ABOVComprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> E q TRUE ARO CORIiFCr. <br /> rT <br /> '356,1298 -- BPick Up ® Delivery ® © U -� <br /> 41 Hauler The Program ID If Site Suffix DATE / ❑❑ / Facility Telephone Number <br /> N <br /> � a [3 WholeTlre Count []Weight in Lbs. <br /> .� � <br /> Volume Cubic Yds: Weight in Tons Name/A, i r �il� 1 <br /> o .Hauler Name., <br /> City sta��llti�d ip4 C�� <br /> N .. <br /> aaEoaalaa stampbr ' <br /> Hauler Telephone Number. ! .Ac�dress, ame as Hauler Tourer,; e' <br /> - •y � /ACIOr 1 C"MFY MAT UNDER PENALTY OF PERJURY OF THE-. .' <br /> �f WROIa Tiros) LAYJBOF THE STATE OF CAUFORNIA TWAT Me <br /> V I���� 1~ y INFORMATION PROVIDED ABOVE S TRUE AMD CORRECT. `; <br /> 1 1 1• •' 1 • 1 - Program ID Site Suffix '1C-ti <br /> 3.56129.8 PCO. . . Pick Up . ❑ Delivery ®)® ® H"' S-0 <br /> 0, <br /> d Hauler Tire Pro ram ID / Site;Suffix Facility Telephone Number , <br /> N g ._. DATE flo <br /> _/ ❑�'/ �® <br /> w Whole Tire Count Weight In Lbs. L, <br /> Facility-,Business PICK•N-PULL <br /> Ej Volume Cubic Yds. Wel ht In Tons. Name/Address <br /> ❑ g 3927 Clark Dr. <br /> ! o Hauler Name }' City,State and Zip Stockton,CA 95215 <br /> U 11) r rn 41r,". ,I <br /> �o Stamp or Label OK <br /> Address Same as Hauler <br /> (/Hauler Telephone�)N♦umber ■_ rnruam <br /> iN/A for uYiB N ST PRA DEo ABO OVE®HTURUE,i1HVTMCORRECT. , <br /> C �� / <br /> Who Tiros) <br />