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Com m rehensrve Tri Number <br /> E:XjAyM,i I L E> 11 <br /> r _ <br /> ciwnleiva�ioius)INSTRUCTIONS ON BACK GlPART 2 DO NOT TAPE DUr�ICATE 3254331 <br /> , STAPLE OR <br /> By signing this CA Comprehensive Trip Log and Receipt,the signer(s)request that the information provided on this form will be considered confidential,proprietary and trade secret. In accordance with Title,14 CCR,Section <br /> 17041 et seq.,If a request is made for disclosure of this information,the CIWMB will contact the signer(s)of this form at the address and telephonenumber provided on thp form or recelpt. �; w <br /> Truck Decal Number Hauler Address <br /> ® © VIP Business Name 7 u � <br /> -- Address 7 <br /> City, State and Zip L� <br /> C <br /> Licensee Plate Number State f l P30 _ //� ) /� , , ) <br /> arrie on ill ,(J`1Ls�'`�W�` —J <br /> L — <br /> I certify under penally of perjury under the laws of the Slate of California that the information provided above Is true and correct.In itiun, am aware that falsification of this inf alion may res u,pensio revocation,or denial of renewal of th <br /> Waste Tire Hauler Registration p and rbiic Resour Codo sectio 42 0" <br /> ay re n c onallies up to$25,000 per ay,p r violation or administrative pe s to$5,000 De talion described in Public Resources <br /> ��r'Aameprint Driver's Si nature <br /> � ) 9 ate <br /> Comprehensive Trip Log Number. Load Information Facility Tire Program ID Site Suffh�:f <br /> 3254331 -- CPickup a''�e�ivery -� <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> � DATE <br /> . oao-ooaaoao <br /> R w � Whole Tire Count Weight In Lbs. <br /> � aCiiity Business <br /> ❑ Volume Cubic Yds.❑Weight in Tons Name/ .ddress <br /> E Hauler Name City, State and Zip <br /> U Stamp or Label OK <br /> a Address Same as Hauler J <br /> Hauler Telephone Number ■ Initials <br /> (NIA for r 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 /> Comprehensive Trip Log Number Load Information Facility Tire Pro ffi <br /> gram ID Site S.W., ix <br /> 3254331 -- B Pick up Delivery <br /> Hauler Tire Program ID / Site Suffix DATEFacility Telephone Number <br /> ON / as a� <br /> w <br /> � Whole Tire Count �Weight m Lbs. <br /> -Facility Business � <br /> m �I D El Volume Cubic Yds.E Weight in Tons Name/Address 7 W <br /> oHauler Name City, State and T /-� <br /> rn V 0 ��'� Q Stamp or Label O <br /> Hauler Telephone Number 000 mono FlAddress Same as Hauler rn s <br /> (N(A for r CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> / Whore Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> 3254331 -- A 00 ® 0D©—� 0 <br /> Hauler Tire Program ID I Site Suffixi Facility Telephone Number <br /> AL, i I <br /> TM© H I D 14 <br /> f f rIcility Business <br /> NamelAdaressko--�q E0. <br /> Hauler Napme City, State and Zip <br /> Stamp or Label O?�C' \r Address Same as Ha FS <br /> Hauler Telephone Number rIT ars .� <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> it j r t - .tom LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> � Y <br /> ` V'. INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> 4 <br />