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I. California Integrated Waste Management Board <br /> SCA Comprehensive Tripp Log and Receipts 10002 P.O.Box 1259,Sammenio,CA 95812-1259 <br /> L_ EjIX A�M P L E 112131 Comprehensive TriNumber <br /> LLLciwu,---BA(iwiwa INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE 3 7 2 5 3 5 9 <br /> By signing this CA CompreheraNe Trip Log and Receipt,the slgn"s)request Net the Irdorewllon provided on this toren will be considered confidendel,prop ietary end red.—.L In accordance wNh Title,14 CCR,Section <br /> t T011 et ser).,N•rsquesl Is mads for disclosure of I tla lnfonnatl n.the Cl WMB.will corset the signer{s)01 this tom at N•address and telephone number provided on this form m receipt <br /> Vehicle Information Hauler Address <br /> Truck Decal Number Business Name . <br /> ® Address � �f�'' � Z--T <br /> City, State and Zip <br /> LiceLnse late Number � State <br /> f� Iq <br /> n® L1J ® H ® © H � ❑ Cameron �J <br /> I <br /> I certify under panalty of perjury under the Laws of the state of Califamia aw the Information provided above is true and meed In addition,1 am re that talaiamtion bijn Uon mayrasua in wspenslon,invocation,o,denial of renewal W MrWasteTea Hauler Registration pursuant to Public Resources Code seNon 12960 end may mutt n cm penalties up to$25.000 per day.per vio tlt}p a admnbtrativ� o$5.000 per vblatlori per day as desalted in Public esourees <br /> Cade section 12962 Y <br /> Driver's Name print <br /> Driv is Signature I ate <br /> Uealso w+mY/w UWg O[D M @ 'qh <br /> [3725359 ED <br /> Pick UpDeli ly ❑ ❑ ❑ ❑ ❑ ❑ ❑�❑ ❑ <br /> Facility Telephone Number <br /> )C Hauler Tire Program ID / Site Suffix; DATE' ❑❑ ❑❑ <br /> N DOE . <br /> Weight In Lbs. -0000000 <br /> w E] Whole Tire CountEl <br /> a Fcility Business <br /> y <br /> VoIumeCubicYds.FJ <br /> . Weight in Tons Name/Address <br /> E <br /> Hauler Name <br /> City,State and Zip <br /> N <br /> �j Stamp or Label OK I <br /> a ❑ Address Same as Hauler J <br /> Hauler Telephone Plumber ❑ rnrrrars <br /> C (N/A I CERTIFY T E UNDER PENALTY IM PERJURY E THE <br /> Whole,Tires) ��OF THE STATE OF CALIFORNIA THAT THE U <br /> ��Y�`('�Y'�yj'��.p.-� MM <br /> :`(� INFORMATION Pct-R�OO�VV,IIDDED ABOVE Is TRUE AND CORRECT.1ro�,/tel��s�f�n�_-�/ <br /> ` All7lA19XI AAM UIf110) 0 0 U�A.'.AAAA:) 0 O 0 0 G� Dw 0 0 � ILK@l:.tilVlll 1. <br /> C7 2,53 5 9 Pick �p RD) DeiidePy <br /> C 4) Hauler Tire Program ID / Site Suffix DATE �® Facility Telephone Number Ir�� <br /> aw Whole Tire Count ❑Weight in Lbs. 1 <br /> tkl' <br /> litu sy �� 110% o olume Cubic Yds. Weight in TonsAid,- <br /> 4) , ` <br /> o Hauler Name. 1. <br /> n `^" w�Y <br /> ser �7 W <br /> 7 <br /> v i s 00EED. <br /> •Star 00 r s@np�Sameas7ia'ufer0.)auler Telephone Number ❑ /nmals ' r <br /> J (N/A forI CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE. _ <br /> 1,�-�+�,,., INFORMATION PROVIDED A90VE IS TR E AND CORRECT. <br /> o p = �° o a 11J,JAA.I°J.31 o, a o 0 / � a o • �D Gula <br /> 3725359 QPick up � DeViv�Iy <br /> �� ® © ❑ <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> DATE OK <br /> m ww Whole Tire Count Weight In Lbs. e 1 n <br /> E �y r_, g Cy Be seine • <br /> lido Volume Cubic Yds. ❑Wei ht In TonsAdE%�ss� I� u <br /> o Hauler Na le ( '"''„'t�"'' <br /> StaQD Ic / i <br /> Hauler Telephone Number a U ❑ Elass amens HaLur�r Initials /1( <br /> "'Ib <br /> //_ D (N/A for f CERTIFY THAT UNDER PENALTY NI PERJURY E THE /I <br /> r —(rJ LAWS MA THE STATE OF CALIFABOVE IS T THAT THE <br /> Whole Tires) INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. l <br />