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_ ) <br /> Com renensive Tri Number <br /> 420265071 <br /> ..; � <br /> ..._ <br /> Section <br /> stale•/GfM4mle INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE <br /> Me 203(104SS) tio <br /> B7049et seq is a CA Comp fshmade far hclowre of ensive Trip Log and Receipt <br /> eip nthe a Son, <br /> e 5)request that CpNM6 vri Icont+ ae sfg erlal eihm°nn at the address and bel.PhonorM will be considered onumber Provided on ttary andhis farm ode rereceipt <br /> �o�artra vAth Title,14 CCR, <br /> thi <br /> vehicle information Hauler Address LA NA 1 V w t I 5 <br /> Truck Decal Number Business Name an �A4 <br /> a a U <br /> City, State and Zip <br /> License Plate Number State C,V0 C, C A y S Z �5 <br /> ® a ® N LR I Corrlr, ran <br /> © ❑ ❑ farrier <br /> 'Wtio r day as described in Public Resources <br /> I certify under panalry of perjury under the laws of the Slate of California that the informa6an provided above Is true and cortecL In addition,1 em aware al fall'cation of This info bon may result in suspension, vocation.or denial of reneeal of t <br /> Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to$25,000 per day,per vidatio orad istrative penalties to$5.00 Q <br /> Code section 42962 <br /> ! is Signature Da e <br /> Driver's Name(print) •• <br /> ickU Delivery 1 o a U9 -o 0 <br /> 4202650 C L]°- Facility Telephone Number <br /> d <br /> � Hauler Tire Program ID 1 Site Suffix DATE <br /> �� � � ®❑ <br /> yy�y ❑ ©® <br /> N <br /> v or <br /> � Irl❑ <br /> y _ <br /> � W Whole Tire Count Weight in Lbs. ifilmS <br /> R Mhz ddrems <br /> H volume Cubic Yds.❑Weight in Tons d its-r a-, `_d - <br /> City <br /> c (� a <br /> O iia uI' 4it'I: /(f <br /> rl t SiL/Ji <br /> £€ar2rsS Same as ttlal,l11'r.44A Initi s <br /> fj <br /> 0000NOBE Z ERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Hauler TelephotleN'unnhei' (N/A for LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> 17f^, Whole Tares) INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> CA 14 <br /> Z IVf •• <br /> Pick Up <br /> 4202650 B Fl- Delivery <br /> Facility Telephone Number <br /> a"i Hauler Tire Program ID ! Site Suffix DATEE® l._ <br /> 00E-@q <br /> e <br /> W i ht in Lbs. <br /> 11.1 Whole Tire Count 9 <br /> �c(tlty Bs,st,�P :r� <br /> i volume Cubic Yds.❑Weight in Tons lt'Jts r' <br /> L <br /> o l-iauler Name _ 6 �ft+C�/�%t <br /> ff r� >-tasnn ee Label QK` �� Zc <br /> 7 I�v V t�t40 ~ <br /> c� +y a ■ ❑ Address Same as ��aule( ,n;�/s <br /> Ij jtauler Telephone l3lLliiit3 r' (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 /> �) •• � <br /> 11111115.-• • • <br /> Pick U Delivery ! a —� E <br /> .. 4202650 AL I <br /> Up a <br /> Faciiity Telephone Number <br /> DATE ® / ©o f <br /> � w Hauler Tire Program ID / Site Suffix ❑❑ H—HPOHNR Sw <br /> Wei ht in Lbs. <br /> a Whole Tire Count 9 C Wti l Q.3 <br /> --; -rl <br /> I E]volume Cubic Yds.❑Weight in Tons <br /> o '-iau.er a a13 CMA rrsE <br /> �___J Address..arr'fe as;-tazs,>rr Initfals <br /> t <br /> �,� )� !`liil'l:1�r I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> (N/A for LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> 8� f,• /`{ f fl Whole Tires) INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />