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(E XjAjMjPILjEj "111' 13J r� <br /> awMema(olros)INSTRUCTIONS ON BACK C ART 2 DO NOT TAPE,STAPLE OR Dl ;ATE - 3 J O 2-5 <br /> . 0 <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,,.._,,rietary and trade secret In accordance with Title,14 CCR,Section <br /> 17041 of 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 lorm or receipt <br /> Truck Decal Number Hauler Address <br /> DR ® ® Business Name ` � �© Address 37,30 P. (� 4>�"'ILicense Plate Number State City, State and Zip <br /> 2 ® R 1fl ® 9 ® f![ Carrie on <br /> I certify under penalty of perjury under the laws of the State of California that the information provided above is true and correct.In addition,I afaware that falsification of this information may result in suspension,revocation,or denial of renewal of tht <br /> Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to f 25,000 per day r violation or administrative penalties up to$5,000 per violation per day as described in Public Resources <br /> Code sect <br /> -�—Itr <br /> Driver's Name(print) rl e s Signature Date <br /> Compreheniiive • . . . . . Information Facility Tire Program <br /> x <br /> o3 3 0 2 5 6 9 -- G Pick u Delive <br /> m <br /> r ryaaaaa 0--r—,1-01 <br /> Hauler Tire Program ID / Site Suffix <br /> Facility Telephone Number <br /> DATE /• l �/� - <br /> aoo-aaa� ooa <br /> ry <br /> Lu Whole Tire Count Weight in Lbs. �. <br /> g a ` rFaciiity.Business <br /> m I 1 ❑ Volume Cubic Yds tj Weight In Tons Name/Address <br /> E Hauler Name <br /> "ext City, State and Zip <br /> U) <br /> �j Stamp or Label OK <br /> a Address Same as Hauler <br /> Hauler Telephone Number ■ 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 /> • • • •• Number • • • • Program <br /> 3 3 0 2 5 6 9 -- Pick uP _ e�ivery, D 0 � 0D 0—F <br /> Hauler Tire Program ID / Site Suffix <br /> 00 <br /> Facility Telephone Number <br /> °' <br /> DATE <br /> F- hole Tire Count El <br /> Weight in Lbs. <br /> -' Facility Business <br /> LH� <br /> Volume CubicYds.�Welght In Tons NamelAddress <br /> oler Name City, State and Zip <br /> or Labe! OK <br /> Hauler Teleptlone Number ■ Wdress Same as Hauler Initials <br /> _ (N/A for C TIFY 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 /> 3302569 <br /> Hauler Tire Program ID / Site Suffix i Facility Telephone Number <br /> Facility Business <br /> I � •>_ � � lVaiTIG/Addf"eSS �� � <br /> Hauler Name City, State and Li <br /> —J , - Stamp or Label OK <br /> Hauler Telephone Number ) Address Same as Hauler Initial <br /> `e > I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> +v���{ ) r., s7• LAWS dF THE STATE OF CALIFORNIA THAT THE.- <br /> COR <br /> n �J INFORMATION PROVIDED ABOVE IS TRUE AND RECT. « <br /> �Y <br />