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Toll Freft6-896-0600 / www.ciw 11c3v/Tires/ <br /> Californla Integrated Waste Management Board <br /> CA Comprehensive Trip Log and Receipts X0002 0.�><,zase siventD,CA8bti12_ b <br /> Compre Tri Number <br /> o 67358 <br /> INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE <br /> aw at/mvs� <br /> By slsigning this CA f?omprehetlsNe Trlp Log and ReealpC the slgller(s)request that the Information provided on this form will be cotrsWered conOden0al,proprietary and trade secret In accordance with Title,14 CCR,section <br /> 17041 at seq.,H a request is made for disclosure of this•nformatlon,the CFWMB will contact the signals)of this form at the address and telephone number provided on this form or receipt <br /> Vehicle gtformation__ --. <br /> Truck Decal Number Business Naliie TPID# 1000065-01 <br /> 111101 _ D N 9 ® H Address Roman Tires INC. <br /> City, State and Zip 800 Laurelwood Road <br /> License Plate <br /> �jNumber <br /> O E H �� Siete � Santa Clara, CA, 95054 <br /> 2 <br /> I certify under penalty of perjury under the laws of the State of Cahforno that the information provided above is true and correct.In addition.I am aware that falsification of this information rney'esu suspension.revocation.or denial of renewal of th <br /> Waste Tire Hauler Registration pursuarrt to Pub[ Ree��°O��ces Code section 42960 and may result in evil penalties up to S 25.000 perday.per violation or administrative penalties up to 55.040 per violation per der described in Public Resources <br /> Code section A 6 <br /> ...-• - / /� <br /> rw 7tzn G ` V <br /> river's Name(pri Driver's Signature ' Date <br /> Comprehe . . Program <br /> 4 0r =� 8 -- Pick Up o Delivery <br /> ® Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> DATE 000 opoopon <br /> W ❑ Whole Tire Count o Weight in Lbs. <br /> — volume Cubic Yds.❑Weight in Tons <br /> E <br /> 0 <br /> U Q <br /> (N/A for 1 CERT FY THAT IA0DEA pEKALTY OF PERJURY OF THE <br /> Whole Tires) LATS OF THE STATE OF CAUFORtaA THAT TRE <br /> ■tEGRUATIM PROV®®ABOVE L4 TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> g 4067358 -- B Pick Up Delivery <br /> � Hauler Tire Program ID / Site Suffix , <br /> Facility Telephone Number <br /> DATE <br /> . a "ires0w Whole Tire Count Weight in Lbs.� n <br /> ltD ff� - -01, o Volume Cubic Yds.®Weight in Tons Boo Laurelwood Road <br /> C1Santa Clara. CA 95054 <br /> ( DOE 4(38 988-4242 <br /> ♦♦ //�� R.00 <br /> /Mlfa/s <br /> Ul— ['�,r��� (N to for i F'/T UNDER PENALTY OF PERJURY OF THE <br /> �`✓J ��Th,* <br /> OF THE <br /> STATE OF CAIffORN1A THAT T}� <br /> (JX <br /> PON PROV®D ABOVE tS TRUE AND—CORRECT- <br /> Comprehensive Trip Log Number Load Information Facility Tire Program <br /> 4067358 -- A Pick Up Delivery <br /> m Hauler Tire Program ID / Site Suffix DR Facility Telephone Number <br /> � DATE 9L� <br /> uj Whole Tire Count []Weight in Lbs. -- <br /> Volume Cubic Yds. [:]Weight in Tons l? /5- "' -k- <br /> U l� <br /> G/ TiesJ/V C T' 60'a l Q S 3 3�� <br /> ■ <br /> r nc oco n rm.,ru,•n= <br />