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rlwMe2o3(low)INSTRUCTIONS ON BACK C ART 2 DO NOT TAPE. STAPLE OR Dl ;ATE 3302568 By signing this CA Comprehensive Trip Log and Receipt,the signer(s)request that the information provided on this form will.3e considered confidential,_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 thls form or receipt rZ Hauler Address ~ Truck Decal Number Business Name _ ® ® Address 3-730 P. City, State and Zip License Plate Number State D ne U ® M�] Q ® ® P� Carrieron I---- � I certify under penalty of perjury under the laws of the State of California th at the information provided above Is true and correct.In addition,I aN aware that falsification of this information may result in suspension,revocation,or denial of renewal of fix Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to$25,000per day r violation or administrative penalties up to$5,000 per violation per day as described in Public Resources Code sect Driver's Name(print) n er's Signature Date Comprehen�ive Trip Log Number Load Information Facility Tire Program ID Site Suffix -- Pick Up 3302569 a o a a o H o Hauler Tire Program ID I Site Suffix n Facility Telephone Number h DATE _ 000-aaoaaoa � w � Whole Tire Count Weight In Lbs. .. Fcility Business ® Volume Cubic Yds Weight in Tons NamelAddress oHauler Name City, State and Zip U) tj g Stamp or Label Oto a Hauler Telephone Number Address Same as Hauler Initials (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOYE IS TRUE AND CORRECT. Comprehensive Triplog Number Load Information Facility Tire Program ID S 'LeSuffix.— iv 3302569 -- B Pick Up j �elivery a a 0 0-0-0 y Hauler Tire Program ID / Site Suffix DATE 00 / 0[] Facility Telephone Number JT Lu_Whole Tire CountE]Weight in Lbs. oao-000aaoo Facility Business m ® 6 ~ El Volume Cubic Yds.❑Weight in Tons NamelAddress Hauler Name City, State and Zip o Q "t-intp or Label OK U Hauler Telephone Number EEEN11MOE ddress Same as Hauler Initials J _ T (N/A for 4CEIRTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND. CT. 3302569 Hauler Tire Program ID / Site Suffix Facility Telephone Number 11/1 41 1 Facility Business(LQ f--V�" ( I f I } NamelAddress t� [/jC � Hauler Name r City, State and zifa ] .-1 ." , �, '� �� Stamp or Label OK Hauler Telephone Number Address Same as Hauler Initials —1 p� ',r v W. t"°'� ''.k I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE _ t lt�i�' , `�T'1. ! LAWS OF THE STATE OF CALIFORNIA THAT THE 7\ f INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.