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Com rehenslve Tri Number <br /> LM E .XjA',raRIP� L I E,", Ii 3 <br /> CINgioa-03s)INSTRUCTIONS ON BACK G. PART 2 DO NOT TAPE,STAPLE OR DU, -ICATE 3254331 <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.,It 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. <br /> Truck Decal Number Hauler Address <br /> (� Business Name'""' <br /> Address <br /> City, State and Zip <br /> License Plate Number � State <br /> E M E-E � u Carrie on LJ <br /> 1 certify under penally of perjury under the laws of the Stale of California that the information provided above Is true and wrrect.In rion, am aware that fafslficatton of this int ation may reR&z:31/-64 al of renewal of the <br /> Wase Tire Hauler Registration p uant iblic Resour Cod 42 0 an y re c enalties up to$25,000 per ay,p r violation or administrative pe s to$5,000 pblic Resources <br /> _ �DriCre (print) Driver's Signature <br /> .Comprehensive Trip Log Number, Load Information Facility Tire Program ID Site Suffik:�"." <br /> 3254331 -- Ci Pick Up ❑ 'Delivery <br /> � Tele Hauler Tire Program ID / Site Suffix Facility Phone Number <br /> U) <br /> DATE <br /> oao-aaoaooa <br /> w Whole Tire Count Weight in Lbs. <br /> EL I Facility Business <br /> ~ Volume Cubic Yds.❑,Weight in Tons Namel:.ddress <br /> Hauler Name City, State and Zip <br /> U Stam, or Label OK <br /> Q <br /> Hauler Telephone Number ■ [:] Address Same as Hauler Initials <br /> (N/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 /> Comprehensive Trip Log Number Load Information U <br /> Facility Tire Program ID Site S ffix <br /> k- 3254331 -- B Pick Up Delivery <br /> ao © o © oa <br /> 41 Hauler Tire Program ID / Site Suffix DATE Facility Telephone Number <br /> w <br /> cc a Whole Tire Count W ght in Lbs. <br /> � � Facility Business <br /> 0 Volume Cubic Yds.❑Weight in Tons Natne;Address <br /> o Hauler Narne City, State and N <br /> rn <br /> UdL -�Lg I J ¢ Stamp or LaM OS CT9 j <br /> Hauler Telephone Number ■ F] Address Same as Hauler In 5 <br /> (N to for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE j <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> is <br /> 3254331 -- A <br /> Hauler Tire Program ID / Site Suffix ( it Facility Telephone Number <br /> 1 J, <br /> t, Nainei(Addresst(,2q <br /> Hauler Name City, State and Lip } <br /> Stamp or Label UFt � 'IQ > <br /> Hfauler Telephone Number Address Same as Haur <br /> Initlats <br /> �^1� t{{-jji I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> f 1 ,2�(/1'. _ �U •J �' LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> y, J �/ / INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />