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Toll FrAM66-896-0600 / www.cjwm1jjAov1Tires1 Cal)forNa Integrated Waste Management Board ? ' CA Comprehensive Trip Log and Receipts 10002 P.O.Box 7259,Sacwmento,CA95812-1259 s�o : Comprehensive Trip Number 3864054 q INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE By algNnq this CA Comprehimelve Trip Log and Recelpt,the signeii1s)mqumt dust the Into on provlded on this form wig be considered confidential,Proprietary and trade secret In accordance wtlb Titre,14 CCR,Section 17041 et seq„H a request Is made for disclosure of this Information,the CIWW wild wrdaetthe signer(a)of this form at the address and telephone number provided on this form or receipt. VehiCielnformailon IITPID# 1000065-01 BusinessNameDecal Number �ss NaB usin s Roman Tires INC. Addre® ® — r,ity, State and Zip 800 Laurelwood Road License Plate Number State Santa Clara, CA 95054 ® a 11 o HE o a (408) 988-4242 I certify under penalty of perjury under the laws of the State of California that the information provided above is true and correct.In addition,1 am aware that falsifiglion of this information may result in suspension.fevomtion,or denial of renewal of th 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 in Public Resources Code section 42962 IM Q r L �� @z Driver's Name(print) Driver's Signature Date Comprehensive Trip . . NumberLoad Information . . QE-- -- `' Pick Up Delivery o 0lity 0ire 0 am ID Site Suffix ❑ ❑ ❑—❑ ❑ m comprel Hauler Tire Program ID / Site Suffix 40- DATE w ❑ leTi (� ❑❑ Facility Telephone Number ❑ ❑❑ C Whore count Wetght in Lbs. ❑ ❑ ❑ ❑❑ ❑ ❑ ❑ ❑ ❑ n Volume Cubic Yds.E1 Weight in Tons y fA � ■ /n/Ba/s I CERTIFY THAT UNDM PENALTY OF PERJURY OF THE (N f/A for nret) 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 3864054 -- B Pick Up DDelivery 2 D D 9 � DiRid CL m Hauler Tire Program ID / Site Suffix ®� ❑❑ Facility Telephone Number DATE a ux Whole Tire count ❑Weight in Lbs. `m f 0;(0' ` Volume Cubic Yds.❑Weight in Tons ,1 6 rn GL i'1 �l C'. � C: o ,�, 200 1Eno �g� • Z-R'THAT UNDER PENALTY of PscT 40F QE a/s n whole nr»a) LAS 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 CLLE: -- A ick Up 0 DeliveryG Comprel e Program 1D / Site Suffix DATE ®® ®LJ ®a Facility Telephone Number Q Whole Tire Count �Weight in Lbs. a 6,, S101 Volume Cubic Yds. Weight in Tons F � � r�h r�to 'R/R/•T96�