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Toll FAM66-696-0600 I www•ciwmAAovlTiresl <br /> Ca ifomia In"rated Waste Management Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O-orehensive1259, to, iA95812—1269 <br /> CompTp Number <br /> s'a'ne <br /> INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE <br /> C/WNB g this <br /> By signing tthis CA Comprehensive Trip Log and Receipt,the signer(s)request that the information provided on this torte will be considered coldldenUal,proprietary and ted'secret In accordance with Title,14 CCR Section <br /> 17041 at seq.,If s request Is made for disclosure of this Informadon,the CM111B will contact the signer(s)of this form at the address and telephone number provided on this farm or receipt. <br /> Vehicle Information --------- - r1000065-01 -- <br /> Truck Decal Number <br /> _usiness dame Roman `fires INC. <br /> _ a ;address 800 Laurelwood Road <br /> 0 011 City, State and Zip <br /> License Plate Number State Santa Clare, CA. 95054 <br /> 000 0 0 [] 0 0 0 - ' L— (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 falsdical,on of this information may result in suspension.revocation,or denial of renewal of th <br /> Waste Tire Hauler Registration pursuant to Public Resources Coya <br /> on 42960 and may result in civil penan—up to 5 25.000 per day.per violation or administrative penalties up to S5,000 per violation per day as described in Public Resources <br /> Code section 42962 / <br /> Driver's Name(print Driver's Signature Date <br /> Comprehensive Trip . . Number Load Information Facility Tire Program <br /> lw� <br /> Pick Up o Delivery 0 000000-0 0 o0 0o Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix <br /> y DATE non upnn000 <br /> = Lu Whole Tire Count Weight,n Lbs. <br /> c� a. <br /> Volume Cubic Yds. Weight in Tons <br /> E <br /> 0 <br /> r <br /> VQ ■ d,�/s .. . <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> (N/A for LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> Whole Tires) INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 3 8 6 3 841 -- Pick Up 0 Delivery <br /> m Hauler Tire Program ID / Site Suffix DATE a as Facility Telephone Number <br /> m - . o_ ' 000 <br /> a Whole Tire Count ®Weight in Lbs. <br /> �Q �O QI�j ® VOlume Cubic Yds.®Weight in Tons Roman Tires INC. <br /> o 800 Ulurelw©od Road <br /> Santa Clara, CA. 95054 <br /> a DOE 9000 (408) 988-4242 /nom <br /> (N/A for i CERTIFY THAT UNDER 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 /> • • - • a • • - • . • e • • • <br /> __ A Pick Up 0 <br /> Delivery <br /> m <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> DATE ® old PHQW � R ® <br /> to <br /> Lu YIhole Tire Count o Weight in Lbs. <br /> 01101010 16 1 Q Volume Cubic Yds. ❑Weight in Tons <br /> o ?af- <br /> t"?f5 <br /> / r a i I. h�o� CA, 9533 C� <br />