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Toll Fr"66-896-0600 / www.ciwm ov/Tires/ <br /> oard <br /> CA Comprehensive Trip Log and Receipts .O.Box <br /> 1259,Sad Waste Management CA95812 259 <br /> ::::: 10002 F.O.Box 1259,Sacramento,CA 95812–i259 <br /> Cpm rehensive Trip Number <br /> '0""""°"" INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE <br /> C/By ignI ng this <br /> By signing this CA Comprehensive Trip Log and Receipt the slgnega)request that the Informagon provided on this form will be considered confidential,proprietary and crad—ecret In accordance vdih Tldo,14 CCR,Section <br /> 17041 of seq.,If a request to made for disclosure of this Information,the CIWMB will contact the signer(*)of this form at the address and telephone nufmv <br /> o <br /> Vehicle Information ; - <br /> Truck Decal Number Hanle rs," Roman Tires INC. <br /> Dusiness Name , <br /> 1/19 -101 oa ,: dress 800 L.aurelwood Roaily, State and Zip Santa Clara, CA 95054 <br /> License Plate Number State (408) 988-4242 <br /> I certify under penalty of perjury under the laws of the Stale of California that the information provided above is true and correct.In addition.I am aware that falsification or this information may result in suspension,revocation.or denial of renewal of tli <br /> Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to$25.000 per day.per violation or administrative penalties up to$5,000 per violation per day as described m Public Resources <br /> Code section 42962 <br /> Driver's Name( rint Driver's Signature Da e <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> ;z C Pick Up Delivery 0 <br /> m Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> DATE o0 00 00 <br /> ono onnoon0 <br /> � LU E] Whole Till.Count �Weight m Lbs. <br /> to <br /> `m U Volume Cubic Yds.❑Weight in Tons <br /> E <br /> r <br /> � t <br /> a ■ iia _�s <br /> for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> (N/A <br /> Whole for 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 <br /> x <br /> 3864062 ®s B Pick Up Delivery <br /> m Hauler Tire Program ID 1 Site Suffix ®a (� Facility Telephone Number <br /> DATE IUM I a l 1 0 w Whole Tire Count We)ght in i bs, a <br /> Ono <br /> , Q j In 1-51I �( Volume Cubic Yds.®Weight in Tons <br /> 1100 Laurelwood Road <br /> Sante Clara, CA. 95054 <br /> �- c (408) 988-4242 <br /> a l a,0 a0 <br /> IDE/ no Ono /Willa/* <br /> (N/A for =11.'T <br /> C TIFY THAT UNDER PENALTY OF PERJURY OF THE ,v <br /> Wo1s�,'.) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROM..ABOVE Is TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> Comprel <br /> CL <br /> A Pick Up Delivery ® o DIE R U-1 <br /> Hauler Tire Program ID 1 Site Suffix U[J <br /> �(� n Facility Telephone Number <br /> DATEtL�JII13 <br /> R ® o ®® ® a ® o ® <br /> UJI ole Tire Count Weight in Lbs. <br /> � Wei ht in <br /> E Q <br /> Volume Cubic Yds. Tons J,r, f log�a r& y <br /> 117row -A a 13-1336 <br />