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E ?C R M•P j L E i !� J I 'I, <br /> Comprehensive Trip Number <br /> Sore u(C.19 m-. 1. 3.2 5 4 3-30 <br /> CfWM82g1(I0105)INSTRUCTIONS ON BACK Ot- TART 2 DO NOTTAPE,�STAPLE OR DUFLiCATE <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 at seq.,If a request is made for disclosure of this Information,the CIWMB will contact the signer(s)of this form at the,address/andd telephone number provided on this form or receipt <br /> Truck Decal Number Hauler Addressi��'�" <br /> ® � ® � Business Name r <br /> -- Address <br /> City, State and Zip 3.7�a N ,(�� UJ� -Q C6 <br /> License Plate Number State ..��� <br /> on <br /> Carrier <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 ad r on, am aware that falsification of this information may result in suspension,revocation,W denial of renewal of the <br /> Waste Tire Hauler Registration pursuant to ublic Reso esn 42�rresult in civil penalties up to E 25,000 pe y. r violation or adminisVaUve Pa up to$5, viol n per day as described In Public Resources <br /> ode 4 <br /> Driver's Name print) river's Signature bate <br /> Comprehensive • Log Number Load Information Facility Tire Programa Site Su I ffix <br /> '. 3254330 nPick Up ❑ Delivery <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> � DATE <br /> w E] Whole Tire Count Weight in Lbs. <br /> Door-oaoaaoa <br /> Facility Business <br /> m D Volume Cubic Yds 1 Weight In Tons Nani e/Address <br /> cHauler Name Cit{, State and Zip <br /> H <br /> V g Stamp or Libel OK <br /> a <br /> Hauler [] Address Same as Hauler <br /> Telephone Number ■. m/va/s <br /> (N/A forI 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 /> • • • •1 •- Load • ♦ •• <br /> 3254330 -- B Pick Up C -Delivery <br /> Hauler Tire Program ID / Site Suffix DATE �, O Facility Telephone Number <br /> y oro as a <br /> AWNhole Tire Count Weight In Lbs. <br /> C 11 <br /> LHatuiler <br /> ,/ ❑ ❑ Facility Business v� <br /> Z. <br /> Volume Cubic Yds. Weight In Tons. Name/Addressome 00H Sti"Ilp or City, State anciaz. 36 <br /> rn C-" <br /> � I <br /> Halder Telephone Number { ■ n Address Same as� /D/ <br /> IN/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 /> r 3254330 -- A <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> ' Facility Business Z <br /> V I '7' � U f✓ Nairne/Addressjb �✓ r+��`� <br /> City, State an1:l Zi <br /> Hauler Name 5� <br /> a Q Stamp or Label OK <br /> ! `� [] Address Same as Hauler m <br /> Hauler Telephone Number <br /> I CERTIFY THAT UNDERPENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE ANO-CORRECT. <br /> I <br />