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low <br /> CA_Comprehensive Trip Log and Receipts 10002 P.O.B'.1259,°,�"'�"CA958 2-1259° <br /> P.O.Box 1269,sacramertto,CA 96812—1269 <br /> CE X A f'r L C 2 - ry' Comprehensive TriNumber <br /> 'w­'. INSTRUCTIONS ON BACK OF PART 2 .DO NOT TAPE STAPLE OR DUPLICATE 403-7140 <br /> J .- <br /> By aWn,ng"CA Comprehenslre Trip log end R•c•tpt the•Want•)reprrst tlret tlr•trrionnatloa wO+W W on w.tuna WM w ca,.worw cardNsidIA wOpfa and ON%w rK In aceordano wdh T108,14 CCR.Boman - <br /> 170H st sep.,I a Iaqu•st b made for dbclusum of fhb the CMM w ll cotdact In signer(s)of this faro at the eddtsas and tabphorr number provided on thb form or receipt• . <br /> vehicle information Hauler Address <br /> Truck Decal Number- <br /> Business Name � ��®� ���� <br /> © © — <br /> [31 <br /> E Address <br /> .© <br /> City,State and Zip `' <br /> License Plate Number State 3730N <br /> . . .WILSON W <br /> 0 �•� © ®.® � © 0 Carrie 1— STOCKTON CA 95` <br /> I candy under penally of perjury under the laws of the State of Cahfomia that the information providedaboveis true and correct.In addifion,I a are 1 felsifiwtion of this info do ey rewtt in suspension,revocation,or denial of renewal of N <br /> Waste Tire Hauler Registration pursuant to P tic Resources Code section 42960 and may.result in dull penalties up to$25.000 per day. i Wtro r administrative panalG .000 pn violatio per day as desrnbed in Public Resou case <br /> Code seeGerf42962 . <br /> Driver's Name(=t' <br /> er's•Signa re D to <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 0 3 714 0 Be'. �+ Pick uP Q( Delivery ) l ct n-� FTJ <br /> kco 4, ❑ ❑ � © ❑ ❑ �� <br /> Hauie�Tire•Progiam ID /. Site Suffix Facility Telephorie.Number` - <br /> DATE <br /> Cd w ® Whole Tire Count Weight in Lbs. �- <br /> m I 0 ❑ Volume Cubic Yds.❑Weight in Tons k��saD�lG&dc�ec8� .oma <br /> c ���r��� , C¢2�,1,3ta4e alsacf•�iq... `; - , <br /> v: •o a1 e'er%: d i TIRE � w <br /> DED y P <br /> \, Stamper i_abs!6K <br /> a 1 �( Address Same as Hauler- ` <br /> N lerglephg� �3 <br /> °, I cERtD•-r TWIT UNDER PENALTY OF PEP JURY of TME <br /> �:•:1l %;•s9' <br /> Whole Tlref LAws Op fl2 STATE OF CALIFORNIA THAT THE <br /> ) INFORMATION PROMED ABOVE 19 TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> r4 0 3 714 0 B Pick Up Delivery <br /> m Hauler Tire Program. / Site Suffix Facility.Telephone Number. <br /> ?; <br /> • � DATE <br /> 7 ooa aoaoao <br /> lu © Whole The Count Weight In Lbs. <br /> 0 1 <br /> m I I Volume Cubic Yds. Welght•In Tons <br /> � tress" <br /> ❑ ❑ i <br /> o fllerrta I VQ1 INutCS Cc` �t:S85 <br /> U :StaMp aV Label OK • ... <br /> E 'Address Same as Hauler <br /> (N lA for I CERTIFY THAT,11mFT1 PEIIALTY-OF PERJURY OF THE- c <br /> Whole Thee) 1AVIS 4 THE STATE of CALIFORNIA THAT THE <br /> • - OIFORNATION PROVIDED ABOVE W TRUE AND cORREcr. . <br /> Load Information Facility Tire Program ID Site Suffix <br /> Comprehensive Trip Log Number <br /> 4 0 3 71.4 0 -- A.: Pick UP <br /> CL <br /> ❑ ❑ ® a ❑ © <br /> m Hauler Tir*Program.ID f Site Suffix Facility Telephone Number <br /> DATE UE-/ <br /> a <br /> W ®Whole Tlre'Count []Weight in Lbs. <br /> Volume Cubic Yds. <br /> ❑Wel ht In Tons 3°�"°c° �' iGw�S <br /> m ❑ <br /> HIn 'dip <br /> AmON TIRE <br /> � a <br /> L � p4�.s0-���3 , � ■ � Address Same as Hauler• �,�y,� <br /> "D 8O )N/A for 1 CERIw V THAT UNDER PENALTY OF PERJURY OF.THE yam✓/ <br /> Wh010 Thee) LATYB OF Tile STATE OF CALIFORNIA THAT THE A <br /> - 01FORYATION PROVIDED ABOVE IS TRUE AND CORRECT. ` .. <br />