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j tr ' ' Jat <br /> Comprehensive TripNumber <br /> X E I <br /> E X R M Fgum <br /> sr.n. ramem;. <br /> 3254-3.3'0 <br /> cmm,32 a(tofos)INSTRUCTIONS ON BACK Ot- r'ART 2 DO NOT TAPE,STAPLE OR DU CATE <br /> By signing this CA Comprehensive Trip Log and Receipt,the signer(s)request that the information provided on this form will be consldered confidential,proprietary and trade secret.In accordance with Title,14 CCR,Section <br /> 17041 el 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 torn or receipt <br /> MIRM <br /> Hauler Address <br /> Truck Decal Number <br /> Business Name r <br /> Address ACIC449(47 <br /> City, State and Zip <br /> License Plate Number State <br /> ® ® © ® R © © L Carrieron S <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 on, am aware that falsification of this information may mutt in suspension,revocation,or denial of renewal of ex <br /> Waste Tire Hauler Registrationrsuant to oblic Reso es`-�n 42�r�suit in civil penalties u to$25.000 e -.-— -Pe P - - P Y Sources <br /> ode� P y{fS Y P P p y. r violation or admintslradve n u to$5, wol n per da as described In Public R�ate <br /> /� Cab <br /> Driver's Name pant) rivers Signature <br /> Comprehensive Trip .. Number Load Information Facility Tire Programs Site Suffix <br /> 3254330 -- C Pick Up Delivery <br /> Hauler Tire Program ID / Site SuffixDATE �' Facility Telephone Number <br /> -0 �0 <br /> Lu E] Whole Tire Count Weight in Lbs. <br /> oaa-oa000aa <br /> (Facility Business <br /> m Volume Cubic'Yds E]Weight In Tons Nana/Address <br /> $ Hauler Name City, State and Zip <br /> N <br /> v Stamp or!.,,bet Ok( <br /> a [] Address Same as Hauler <br /> Hauler Telephone Ntfmbc_=r ■. rnrerars <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tfres) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> • • • •• •- Load • f •• <br /> 3254330 -- B Ll <br /> Pick Up C -Delivery <br /> 0) Hauler Tire Program ID / Site Suffix DATE ( O Facility Telephone Number <br /> N as ao 0 <br /> Mpa-op® p © M <br /> urrWhole Tire Count Weight In Lbs. <br /> n 11 ,/ Facility Business <br /> 0 v� <br /> m Lf I .� 01/ � E] volume Cubic Yds. Weight In Tons Name/Address - t <br /> E Hauler Name City, State and � <br /> z <br /> C45— <br /> Va 00HMRM00 <br /> or LateHauler Telephone Number Cl Address Same a3vile-ro mr <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 /> .q" <br /> f 3254330 -- AD [RID ®-D <br /> -2 <br /> 0 ® <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> T <br /> u. Facility business 2 ✓�-+ <br /> 'No ( Nafrie/Address��pu y �✓ +�"''`: <br /> I City, State anG Z `""� � <br /> Hauler Name <br /> Stamp or Label OK <br /> H [] Address Same as Hauler <br /> Hauler Telephone Number r„ �r <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> 'fir <br />