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o ,O 66-696-06001 www.ciwm"ov/Tires/ <br /> • Ca;rfornia intRpratr3d Waste Management Bn2rd <br /> k CAI Cio�nr� jensive Trip Log and Receipts 10002 P.O.Box 1269,Sacramento,CA 95812—1259 <br /> , Comprehensive Tri Number <br /> .�r. HEALTH <br /> , � tIT 3864668 <br /> �°'.&CWK-11 I N�I.QM>S{4CK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE <br /> Crfsflfe203(MM kete+pt <br /> By signing fhls CA Tdp IDg 911d -the signeris)request that the Information pfoyldgd on thio form ydfl bg onbldered confidential,proptleiary and trade secret.In accordance with Title,14 CCR,Section <br /> 17041 et seq..If a 9for disclosure of this Information,the CIVWMB will contact the signers)of this form at the address and telephone number provlded on this form or recelpt. <br /> yehiclo_Infoimaton <br /> Truck Decal Number C1t,GS` I�at 1e ' �TPID# 1000065-01 <br /> 101 <br /> Address Raman Tires INC. <br /> City. State and Zip 800 Laurelwood Road <br /> License Plate plumber State <br /> a � � � ® ❑ � a � Santa Clara, CA 95054 <br /> I candy under penalty of perjury under the laws of the Slate of California that the information provided abo-is nue and correct.In addition.1 am aware that falsification of this informal—may result in suspension,tevomfion,or dental of renewal of IN <br /> Waste Tire Hauler Registration pursuard to Public Resources Code section 42960 and may result in mt!penalties up to$25.000 per day.per vitiation or administrative penalties up to$5.000 per mistion per day as described in Public Resources <br /> Code section 42962 <br /> Driver's Name(print) Driver's Signature Data <br /> Comprehensive Trip . . Number Load Information Fac ility Tire Program <br /> C Pick Up ❑ Delivery ❑ ❑ ❑ a ❑ ❑ ❑—❑ ❑ <br /> v Facility Telephone Number <br /> � Hauler Tire Program ID ! Site Suffix ❑a � as aL� <br /> � DATE ❑ ❑ ❑ ❑ - 1 _ <br /> W ® Whole Tire Count Weight in Lbs. J <br /> m I s, I ❑ Cubic Yds.❑Weight in Tons <br /> � � I Volume CuE f 2 7 d10 <br /> ENVIRKNIMENT HEA1 FH <br /> a ■ PIE- iiVI1T1LVIGt, <br /> (N/A for I CERTIFY THAT UNCER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive • Log Number <br /> 3864068 -- B Pick Up RDelivery ❑ ❑ ❑ ❑ ❑ ❑ ❑-❑ ❑ <br /> m Hauler Tire Program ID / Site Suffix 2E ❑❑ ❑❑ Facility Telephone Number <br /> DATE IUS�i ❑ I Q ❑1 ❑ ❑ <br /> m <br /> a hole Tire Count Weight in Lbs. <br /> W 11 <br /> m /;0© jJ©i 6� J li ❑ Volume Cubic Yds.❑Weight in Tons 800 ;=--aurelwood Road <br /> E Santa Clara, CA 95054 <br /> (408} 988-4242 <br /> C, a <br /> --d ■ � MAWS IA for I CE3tTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> ("f Whole Tires) EAMB OF THE STATE OF CALIFORNIA THAT THE <br /> fJ DIFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive • Log Number <br /> AP1?—ick Up [IDOE ® 9 ® Q® N-0 <br /> Hauler Tire Program ID / Site Suffix ®® a� ❑®� DATE Facility Telephone Number <br /> Uj E]Whole Tire Count ❑Weight in Lbs. r <br /> Volume Cubic Yds. ❑Weight in Tons11r t <br /> w ..�� f(r'0/� G: qJ -33 <br />