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..........V rrr \{d�rr•/�i� C ^ � Cs,WM820JI(1010a)lNSTRUCTIONS ON BACK l ART 2 DO NOT TAPE, STAPLE OR Dl :ATE `� By signing this CA Comprehensive Trip Log and Receipt,the signer(sr—quest that the information providedon this form will be considered confidential,p-prletary and trade secret.In accordance with Title,14 CCR,Section 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 and telephone number provided on this form or receipt Truck Decal Number Hauler Address ® eea_ ® ® g ® ® Business Name Address City, State and Zip C� " License Plate Number State (� Carmrylrie on -- I certify,under penally of perjury under the laws of the State of Calif—a that the information provided above is true and correct.In addition,I am aware Thal falsification of this Information may result in suspenslon,revocation,or denial of renewal ofttx Waste Tire Hauler Regisuat-pursuant to Public Resources c7,V 42960 and may result in civil penalties up to E 25,000 per day,per vidaaon or mistylive penalties up to$5,000 per violation per day as described In Pubfic Resources Croda settler 42 J - �-- � a Dri Name(print) Driy&s Signature Date Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix,: 1 mpre rHauier 4542 -- C p r . - Pick U a Delivery a 'allre Program ID / Site Suffix Facility Telephone Number DATE .w � Whole Tire Count Weight In Lbs. ® �CL Facility Business E] Volume Cubic Yds. Weight in Tons Nanic/Address E El r Hauler Name City. State and Zip rn V Stzi,np or Labol OK a � Address Same as Hauler Hauler Telephone Number ■ m/Na/s (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. om--rehensive Trip Log Number Load Information Facility Tire Program ID S 3 2 5 4 5 4 2 -- B Pick Up Delivery 00000110 -" 1111 a Hauler Tire Program ID / Site Suffix Facility Telephone Number UD DATE � a � Whole Tire Count Weight In Lbs. aao-oQaaooc R Facility Business El Volume'Cubic Yds.❑Weight in Tons Name/Address o Hauler Name } City, State and Zip U I 0 Sterol t:,r I_abet OK Hauler Telephone Nuinber Q h ■ Address Same as Hauler �S (N IA for ERTIFY THAT UNDER PENALTY PERJURY OF THE Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE !!/••• INFORMATION PROVIDED ABOVE IS TRUE AND CORREC 3254542Lq Hauler Tire Program ID ! Site Suffix Facility Telephone Number Facility Business Narne/Address /�C��, r _� Hauler Name C:"ty, State and Zip/6 ►.(��iC f ;;t;;rn(J or Label OK A�* f Hauler Telephone Number n Address Same as Hauler fn/mals J / •t !' I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE _ LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECt.