Laserfiche WebLink
Nov 05 08 01 : 45p p. 6 <br /> f ::X Ft l4tt _ r„ reetenSWe Trip Number <br /> cow 2onInG this CA ON Bl?hC[4 OF PART Dtl l�fC3T T/�FE,STAPLE OR DUPLICATE' 3231594 <br /> By aipning this C.4 Comprohoosk♦Trip Log antr Receipt the slgner(sj request that the information provfded on.this form will be considered confidential.proprietary and Ira de secret m accordance with Tilt,14 CCR,Section <br /> 17041 at seq.,If a request is made ror dlsclosum of trhis Information_the CMVB will contact the signer(s)of this form at the a"ness and ta'ephone number provided on this form or receipt. <br /> Truck Decal Vurnber f _ 4, <br /> p0qB5 ""i- <br /> License Plate Numtrer State rr -tfi:G:i;S <br /> HIME DIN- <br /> 14 a". 7 <br /> CeM y undar penalty of perjury under the laws of the Stata of Calilornia thal the information prcvioed ab,e'Is true and correct.In addilion.Iam aware Iha:falsifdalion of th5 information ma,•result it suspenslon,revocation,or dent of renewal of Ih <br /> Waste Tre He Wer Reoislra6Dr pursuan!to?uoMc Resources Cole section 4296C and may eaau�t in civil penallloc up!o$ZS,ODO per Cay.Per Wolallon or admin'slrat^•a OeWllie uq to$5,000 <br /> Code so^1100 42862 per violation per day as described In Pubic Resowces <br /> Driver's dame(print) is Signature Date <br /> Comprehensive Trip .. Number Load Information ProgramFacility Tire <br /> Q 3231594 -- Fick Up Delivery Q 0 0 0 11 11-110 <br /> U <br /> I Q) Hauler Tire Program i'i3 / Sitesuffix (�(� Facility Telephone Number <br /> N DATE � IL PP1 ! "� UL(_II'�� I <br /> LU Whoie Tire Conrrt Weight in Lbs. <br /> M <br /> V0lufne Cubic Yds.❑Weight in Tons <br /> U) <br /> initials <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) -AWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVlDEO ABOVE IS TR IIE T. CORRECT. <br /> Comprehensive • •. NumberLoad • • Facility Tire Program <br /> • , <br /> Site Suffix <br /> iz 3231594 -- B Pick Up ® Delivery <br /> U <br /> Hauler Tire Program!D i SiteSuffix (� n� } �{� Facility Telephone NumberDATErA <br /> f� .5 fl IL_C►} i�!J J� j �� <br /> L�1—I LTJ LJ L� <br /> a� <br /> � <br /> - E]Whole Tire Count E]Weight in Lbs. <br /> olume Cubic Yds.Q Weight in Tons t✓ <br /> tt''++''_r.. ■ .. E.a ........ initials <br /> D(� (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> v !J V // WholeTires} LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> Comprehensive Trip Log Number Load 116fdrnia6lolil 'Faicifity INFORMA710N pROVIOED A90VE IS TRUE ANO CORRECT, <br /> Fu- <br /> J M <br /> 3231594 -- 000011110-00 <br /> Facilityhone Number <br /> Hauler Tire Program ID i SiteSuffix <br /> r Telephone <br /> initials t <br /> l CVR,IF(TWAT UNDER PERALY W pER.URY JF THE <br /> IRwS OF THE STATE Of CA2."F ':H TIiAT TrfE <br /> tNFOR.WA7F:7N PROVIDED 4i3.?lrE.f5 ear".T`:.IA�w;CCe7RE�. <br />