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Callfomla Integrated Waste Management Board CA Comprehensive Trip Log and Receipts• 10002 P.O.Box 1259,Sacramento,CA 95812-1259 Ej.X AjM P j L E 2 Z 3 Com rehensive Trip Number crymi,203(,,,)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE 3749052 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 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 Vehicle Informat on Hauler Address Truck Decal Number Business Name Address City, State and Zip �.� License Plate Number ��State r ❑ Cameron �-t Z�--�'C C,4 ( 'S 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 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 Cod.soction 42962 Driver's Name(print) Driver's Signature Date Comprehensive Trip .. Number Load Information Facility Tire Program 3749052 -- =Pick up 1® Delivery1707 ® © © ® ©—© a Hauler Tire Program ID / Site Suffix Facility Telephone Number DATE ©® �� N w Whole Tire Count Weight In Lbs. 0.� Facility'business `� m Clio �.1&1 /71 Volume Cubic Yd..[—]Weight in Tons Name/ }�� I ' E Hauler Name City,S e nd Zip •v) y _ Sta Ad � I Lab �� -Initials Hauler Telephone Number ■ ❑ e Initials (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE -'7 Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE 19 TRUE AND CORRECT, Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 3 7 4 9 0 5 2 -- Br k Up ❑ Delivery ❑ ❑ ❑ ❑ ❑-❑ ❑ 0 Hauler Tire Program ID / Site SFacility Telephone Number me lire Count-QWeight in•Lb . ❑-.❑ ❑ ❑ ❑ ❑ ❑ ❑ ^ility Business e Cubl�Yds. W fight In.Tons -Na /Address- oHauler Name City, tate and Zip UIN Stamp or Label OK Hauler Telephone Number ■ ❑ Address Same as Hauler` C�j (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tlre9) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 3749052 -- A ick up Delivery 1fl HE a © ® ©-0 0 CD Hauler Tire Program ID / Site Suffix DATE Facility Telephone Number a� / a® / ®® m wWhole Tire Count Weight in Lbs. r-� CL fracility BY E v © � CS Volume Cubic Yds. O Weight in Tons Name/Ad3 ss' N Hauler Name n Ci4y,Stat al c� pC-"4 CA �S 0 �1(�J -T\ke �2- S4amp or Label O"at Hauler Telephone Number a DE _❑ Add,'.ss Same as Hauler Initials ^+ I''/7 (�{[ •►rte/ w''rtir..- __--_ ......UNDER PENALTY OF PERJURY OF THE (N/A far TATE OF CALIRNIA Whole Tires) FORMATION PROVIDED ABOV EIS TRUE AND CORRECT.