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!t x�R nlr; t_I1: 1 ; i� i �� ur�rvcl CIWMB203(10105)INSTRUCTIONS ON BACK( ART 2 DO NOT TAPE, STAPLE OR Dl ;ATE vv r 325,4542 By signing this CA Comprehensive Trip Log and Receipt,the signer(st..quest that the information provided on this form will be considered confidential,prvprletary 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 format the address and telephone number provided on this form or receipt. Truck Decal Number Hauler Address Business Name Address City, State and Zip License Plate Number Sta te ig � 1111 ® ® 0— [ . C o mfrr jo n l--- —J I certify under penally of perjury under the laws of the Slate of California that the inforinauon provided ab-,—true and correct.In addition.I am aware that falsification of this Information may result in suspension,revocation,or denial of renewal of th Waste Tire Hauler Registration pursuant to Public Resources Codes ctw 42960 and may result in civil penalties up lu$25,000 per day.per vidauon or inistrAtive penalties up to$5,000 per violation per day as described In Public Resources. Coda section 429 ! _ .57 Dr VName(print) Dri r s Signature Date ---- Comprehensive Trip Log Number Load Information 'Facility Tire Program ID Site Suffix om r, nn Q 3254542 -- C Pick Up bei very` 1=0 Hauler Tire Program ID I Site Suffix Facility Telephone Number DATE no / . Qoo-ooaaoaa lv w Whole Tire Count Weight in Lbsa. . Facility Business d Volume Cubic Yds.❑Weight in Tons Narne/Address E o Hauler Name City. State and Zip In v r?tain1)ori alJel OK p a Address Same as Hauler Hauler Tele hone Nur ■0E Initials (N IA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) IIILAWS OF THE STATE OF CALIFORNIA THAT THE Millimmimer INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT, Comprehensive Trip Log Number.� Load Information Facility Tire Program ID S ite Suffix 3254542 -- B Pick Up Delivery D D D O d-0 0 a Hauler Tire Program ID I Site Suffix DATE / a® / ®® Facility Telephone Number . aaa-oaaaaoc � wa � Whole Tire Count �Weight m Lbs. r FCi?ity Business. y ® ~ Volume'Cubic Yds.❑Weight in Tons Name/Address E Hauler Name City, State and Zip U) niEOEO Sirif!-I!o n;'t_afdci lr�Hauler TeleOhone Nlurrnl.1,,r Address Same as Hauler � J (N/A for CERTIFY THAT UNDER PENALTY PERJURY THE WWholele Tires) LAWS OF THE STATE OF CALIFORNIAI THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORREC 3254542 -- A ��. © © ® �' L�10-17-71 Hauler Tire Program ID / Site Suffix Facility Telephone Number facility Businessoi-r_li NarnetAddress I " *do Hauler Name a k' C"ty, state and Zip/b, ft i `.:t..:my:r or t_ahei 045 Hauler l elephone Number n Address Same as Hauler Initials I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE / i t\ OF THE STATE OF CALIFORNIA THAT THE C. INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.