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Callfomla Integrated Waste Management Board CkComprehensive.Trip Log and Receipts 10002 P.O.Box,259.SacrementD,CA958t2-;259 ' E{x AIM P E < 2 3 Com rehensiveTri _Number' crwNem,` r"iao's�INSTRUCTIONS ON BACK OF-PART 2 DO NOT'-TAPE,STAPLE OR'DUPLICATE 3 6 5 5 7`C.- By algning this CA Comprehensive Trip Log and Receipt,thi signor(s)mqusat that the Information provided on twa form win be considered confidential.proprietary and trade secret.In amordance with Title,14 CCR,Section - 17041 at seq.,If a request Is crude for disclosure of this Irdomhetlon,the CIWa48 will contact the slgner(s)of this form at the address and telephone number provided on this form or racafpL Vefi c e7 nfoirtlatlon Truck Decal Number Hauler Address = n Business Name . Wingfoot Commercial Tire 1 ® 9Z 0 Address 1000 S. 21 St Street City, State and Zip License Plate Number State Fort Smith AR 72901 - .� .� ❑ ® CarrCommon Carrier I cortify under penalty of perjury under the laws of the State of California that the information provided above Is true and correct.In addition.I am avers that falsification of this information may result in suspension,revocation•or denial of renewal of tis Waste Tire Hauler Reglsbation pursuant to Public Resources Code secgori 12960 and may result in cM penaWes up to S 25.000 par day,per violation or ad tiadve penalties up to$5,000 per violation par day as described in Public Resources j Code section 42962 s, 1-4 : Q„ Q: 2f li 2 Drive 'ser'`Sig Date. . Name(print �riv Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix '3655759 -- C Pick UP;O'*-[] ❑ oQoaoo-oa Facility Telephone Number Hauler Tire Program ID / Site Suffix a� ❑❑ j DATE y ❑ ❑ �-Boos © ❑-o w Whole Tire Count [•Weight in Lbs. 411 a g Facility Business L61 tie yZ r. , Volume Cubic Yds.❑Weight in Tons Name/Address 1 E Hauler Name City'State and o � 3S6 A{Dr v Stamp or Label OK a Hauler Telephone Number ■ Address Same as Hauler fnitlah I (N lr l CERTIFY THAT UNDER PENALTY OF PERJURY THE _ Whole 1a Tires) LAWSLAWSTH OF E STATE OF CAl1FORMA THAT THE ....,._ INFORMATION PROVIDED ABOVE Is TRUE AND CORRECT. T! Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix I! rATE 3:65557 5 9 -- B Up Delivery CIL U ❑ ® ❑ '• Facility Telephone Number Hauler Tire Program ID / Site Suffix Wei ht in Lbs.Tlre Count 9FacilityBusirWingfoot Commercial Tire ( El e Cubic Yds. Weight In Tons Name/Addre�4045 N Wilcox RdE City,State arStOCkton CA:95215 0 Hauler Name FUMStamp orLabel OKHauler'.Telephone Number Q AddressSame as.Hauler..(N iA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) - - LAWS OF THE$TATE OF CALIFORNIA THAT THE /! 2 INFORMAnON PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix mprel a Pick Up Delivery © a U—a F .36555.9' .A ❑ ❑ 0 ® ® 4) Hauler Tire,Program ID / Site Suffix Facility Telephone Number ` DATE / a ®Whole Tire Count El in.Lbs. © � ® ©00Do © 0 g Facility Business, j 4Z y i 1 E] Volume Cubic Yds. Weight In Tons Name/Address E City,State and o Hauler Name p Stamp or or La e'6k C V a ) J aAddress Same as Hauler rnitrars Hauler Telephone Numberail ■F. n E] (N/A 10r I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole area) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION,PROVIDED ABOVE IS TRUE AND CORRECT. I