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COMPLIANCE INFO
Environmental Health - Public
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EHD Program Facility Records by Street Name
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ROBERTS
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12742
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4700 - Waste Tire Program
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PR0534900
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COMPLIANCE INFO
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Entry Properties
Last modified
4/4/2019 10:13:55 AM
Creation date
4/4/2019 9:58:42 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4700 - Waste Tire Program
File Section
COMPLIANCE INFO
RECORD_ID
PR0534900
PE
4740
FACILITY_ID
FA0020181
FACILITY_NAME
COSTA FARMS
STREET_NUMBER
12742
Direction
S
STREET_NAME
ROBERTS
STREET_TYPE
RD
City
STOCKTON
Zip
95205
APN
19115004
CURRENT_STATUS
02
SITE_LOCATION
12742 S ROBERTS RD
P_LOCATION
99
P_DISTRICT
003
QC Status
Approved
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CField
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EHD - Public
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Callfomla Integrated Waste Management Board <br /> CA Comprehensive Trip Log and Receipts• 10002 P.O.Box 1259,Sacramento,CA 95812-1259 <br /> Ej.X AjM P j L E 2 Z 3 Com rehensive Trip Number <br /> crymi,203(,,,)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE 3749052 <br /> By signing this CA Comprehenalve Tdp Log and Rac.lpt the slgner(s)regLvW that the Information provided on this form will ba considered confidential,proprietary and trade s.crat In nccorda with Title,14 CCR,Section <br /> 17041 at seq.,N e request 11 mad.for di..I—tire of this Int—tion,th•C11NYB will—orect If.slpner(s).1 mi.form n me address and telopt,—numb-provlded—this form or—Ipt <br /> Vehicle Informat on Hauler Address <br /> Truck Decal Number <br /> Business Name <br /> Address <br /> City, State and Zip <br /> �.� <br /> License Plate Number ��State r <br /> ❑ Cameron �-t Z�--�'C C,4 ( 'S <br /> I uarLfy under penalty of penury under the laws of the State of California that the information Pr.vid.d above is Lrue and correct.In addition,I am swam that fal,lfidabon of this information mzwfgult in—pension.revocation.or denial o1 renewal of NI <br /> Waste Tire Haular Registration pursuant to Public Resources Code section 42960 and may rosull in—il penalties up to$25,000 per day,por violation or adm' penalli to SS r violation per day m described In Public Resources <br /> Cod.soction 42962 <br /> Driver's Name(print) Driver's Signature Date <br /> Comprehensive Trip .. Number Load Information <br /> Facility Tire Program <br /> 3749052 -- =Pick up 1® Delivery1707 ® © © ® ©—© a <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> DATE ©® �� <br /> N <br /> w Whole Tire Count Weight In Lbs. <br /> 0.� Facility'business `� <br /> m Clio �.1&1 /71 Volume Cubic Yd..[—]Weight in Tons Name/ }��� I ' <br /> E Hauler Name City,S e nd Zip •v) <br /> y _ <br /> Sta Ad � I <br /> Lab <br /> �� -Initials <br /> Hauler Telephone Number ■ ❑ e Initials <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> -'7 Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE 19 TRUE AND CORRECT, <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 3 7 4 9 0 5 2 -- Br <br /> k Up ❑ Delivery ❑ ❑ ❑ ❑ ❑-❑ ❑ <br /> 0 Hauler Tire Program ID / Site SFacility Telephone Number <br /> me lire Count-QWeight in•Lb . ❑-.❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ^ility Business <br /> e Cubl�Yds. W fight In.Tons -Na /Address- <br /> oHauler Name City, tate and Zip <br /> UIN <br /> Stamp or Label OK <br /> Hauler Telephone Number ■ ❑ Address Same as Hauler` C�j <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tlre9) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 3749052 -- A ick up Delivery 1fl HE a © ® ©-0 0 <br /> CD Hauler Tire Program ID / Site Suffix DATE Facility Telephone Number <br /> a� / a® / ®® <br /> m wWhole Tire Count Weight in Lbs. <br /> r-� CL fracility BY <br /> E v © � CS <br /> Volume Cubic Yds. O Weight in Tons Name/Ad3 ss' <br /> N Hauler Name n Ci4y,Stat al c� pC-"4 CA �S <br /> 0 �1(�J -T\ke �2- S4amp or Label O"at <br /> Hauler Telephone Number a DE _❑ Add,'.ss Same as Hauler Initials <br /> ^+ I''/7 (�{[ •►rte/ w''rtir..- __--_ ......UNDER PENALTY OF PERJURY OF THE <br /> (N/A far <br /> TATE OF CALIRNIA Whole Tires) FORMATION PROVIDED ABOV EIS TRUE AND CORRECT. <br />
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