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Nov 05 08 01 : 44p p. 4 <br /> - - - - - --- ugav•VR aT� o alw w..I. <br /> natnw California Integrated Waste Management Board <br /> ^_ CA CQ��xaprehenlsive i rip Log .and Receipts i0 P.C,Bost t259•,Sacramento,CA,95872-T259 <br /> X A M. L E —_ ' _ _ Comprehensive Trip NuMber <br /> c2[nurvm,., <br /> c��ts%s2oaimrosl INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE 3234308 <br /> By signing this CA Comprehensive Trip Log and'Raceip(,the signarlsl request that the information provided on thls form will bo considered conliidential,proprietary and trade secret.n accordance with Tlle,14 CCR,Section <br /> 17041 et seq..If a request is made Ior diia.losure of this information,bye CIWPAS w11.contact the signor(sl of tots loan at the address ono teleph0na number pro wded on[nis form or receipt. <br /> TFefck Dec2i Number h8:4iEr Aa'3r8SSsiale al <br /> a 27 <br /> Lscense Folate P;arabsr SfOe <br /> H [� HSEBD Ed <br /> Y <br /> ceM1•ly unser penally o]perjury undnr Inc laws of the Sleto df California:hat Ih0 in(0Tn♦lion prc.id.d above Is Irue and cOrrecL in atldlllon, am aware that falsification Of lois inlOrmadon may realin suspension,reu0ceU0n,or derua.'0,renewal of 1 <br /> Waste Tim Hauler Registfation pun uanl W Public Resources Code 6ecfl 42960 and may result in avil penalties up to$25,000 per day,per violation or administrailve peneldes up to$5 00 per violation per day es described In Public Re6ourcas <br /> COae section 42962 - <br /> Driver s!/fame(print) Driver's SignatureComprehensive to <br /> . Log Number Load Information Facility Tire Program <br /> x <br /> 3234308 C Pick Up De livery 0-0 IT <br /> U <br /> m Hauler Tire Program ID I Site Suffix Facility Telephone Number <br /> � 9 DATE � <br /> y LLL���fffQ �-aoDoao <br /> wa Whole Tire Count Weight in Lbs. <br /> Volume Cubic Yds. Weight in Tons <br /> E <br /> o <br /> D : . <br /> l'Sa:..... <br /> 7!i �, Q MOD L— <br /> .'. ~G� a'?'. 2£. <br /> (N fA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole TIIBs) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip • • Number Load InformationProgram n n <br /> x <br /> 3234308 -" B Pick Up 1 91 j[�FbeliveryLJ <br /> v <br /> Hauler Tire DATE Site Suffix ID Program 1 Facility Telephone Number <br /> � 9 ( / / U <br /> ro tugWh le Tire Count Weight in Lbs. <br /> Qa ®-� oa �o <br /> m i ! I U ..>. f ~ Volumd Cubic Yds.E]Weight in Tons/ ,l k✓ <br /> �•- t - via <br /> fn <br /> C7 �� �- l 5 Q V <br /> �I_, ._. i ■ _ r35 �� .'ri.`. initials <br /> 1, ,'j1 1 (N fA fol I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE t <br /> ��✓ /� V V / Whole T1re5) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRU AND CORRECT. <br /> ru?~TComprehensive Trip Log NumberF.• InformationProgram i <br /> Site Suffix. <br /> Hauler Tire Program 10 1' Site Suffix rY P.; _ 'FaciEFfyr Telephone Number <br /> 3i D000000 <br /> ► i i ... mei r." ! <br /> a <br /> initials- <br /> . UNDER PENALTY OF PI RJU,lY OF THE <br /> mar i 1 <br /> r r�,.,.o^ ♦wr.- ,ta +` (.,f;WS 0 E STA.0 Or CALIFORNIA THAT THE .. <br /> '�'' "'•3r' -.r' ! INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />