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Toll FrL ,66-896-06001 www.ciwml �ov/Tires/ <br /> California Integrated Waste Management Board <br /> 10002 Box <br /> CQ Comprehensive Trip Log and Receipts <br /> .: e. <br /> comprehensive Tri Number <br /> 3663763 <br /> .•:: <br /> am INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE <br /> By signing tills CA comprehensive Trip Log and Recelpt,rhe signer(s)request that the Infoml provided on this form will be considered conMential,proprietary and trade secret In accordance wish Title,14 CCR,Section <br /> Truck Decal Number 4 <br /> vehicle Information ®�nrormwon,the CMM wilt contact the a gb%twr(s)of this form provided <br /> form at the address stelephone manlier on this 0065'0 1 <br /> ek <br /> Business Nar�e Roman Tires W. <br /> Iddress800 Laurelwood Road <br /> Sf8 8 ai,cl iii} �l <br /> License Plate Number State Santa Clara, CA. 95054 <br /> (408) 988-4242 <br /> I certify under penalty of perjury under the laws of the State of California that the information provided above is tore and correct.In addition,I am aware that falsification of this information may result in suspension.revocation,or denial of renewal of IN <br /> Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to S 25.000 per day.per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources <br /> Code section 42962 O r p �`J/�}n e z— <br /> Driver's Name(print) Driver's Signature Date <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> Compre, <br /> L— <br /> *' <br /> miss `' Pick Up ❑ Delivery [] ❑ [� ❑ ❑ ❑-❑ [71 <br /> O <br /> vFacility Telephone Number <br /> Mi Hauler Tire Program ID / Site Suffix DATE ❑❑ . �� - �� <br /> U1 Whole Tire Count Werght m Lbs. <br /> Ono nnn000n <br /> as <br /> Volume Cubic Yds.❑Weight In Tons <br /> � a <br /> � /n/daLs <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> (N I/A fbr le Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> WillINFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> sit- <br /> 3863763 w' BTuffixDATE, <br /> Pick Up Delivery 0000000-00 <br /> Hauler Tire Program ID / Site SEff <br /> ®® 110 <br /> Facility Telephone Number <br /> CholeTine Count Weight in Lbs.DVolume Cubic Yds.❑Weight in Tons 800 Lau relwood Road <br /> E Santa Clara, CA. 95054 <br /> ` r (408) 988-4242 ctn <br /> �f �/ 6 h(IN/A for kT UNDER LAwS GF THE STATE OF CALIFORNIAFTHAT THE OF PERJURY F THE <br /> U( A? t7 � ( � " <br /> Whole Tfrolt) <br /> WFORMATION PROVIDED ABOVE ISTRUE AND CORRC-CT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> o. - A ickUpDelivery <br /> Hauler Tire Program ID / Site Suffix DATE / Facility Telephone Number <br /> n Whole Tire Count E]Weight in Lbs. _ <br /> Volume Cubic Yds. Weight in Tons <br /> o <br /> e—Y4c f <br /> a <br />