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California Integrated Waste Management Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento;CA 95812-1259 <br /> E(X A�M PILE 1 2 3 � Com rehensive Tri Number j <br /> 1 425T12 <br /> law sra` INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE <br /> By signing Nis CA Comprehensive Trip Log and Receipt.the slgnerls)request that the Information provided on this form will be considered confidential,proprietary and trade secret.In accordance with Tree,14 CCR,Section <br /> 17041 at seq.,11 a request Is made for disclosure of this Information,the CIWNIB will contact the signers)o1 this torte at the address and telephone number provided on this form or receipt <br /> Vetiiclellnfotmation <br /> Hauler Address <br /> Truck Decal Number me lg.ps ���r� �1 <br /> Business Nat/'iJyJ (9� I <br /> © � — © ® [2] © Address �!� f Pr✓ ��Va�- gkl <br /> City, State and Zip 7 <br /> License Plate Number State © /C CP C/}' (Ov'9 <br /> ® © � © .© ® NEE � CCom <br /> arrie on <br /> 1 certify under penalty of perjury under the laws of the Sat f California that the information provided above is Wo and correct.In addition,I em aware that f8tsification Of this information may result in suspension.revocalion,or denial of renewal of N <br /> Waste Tire Hauler Registration pursuant to Put-Resour 1.Coda section 42960 and may result in civil penallies up to S.2 5.000 per day.per vl0iation r adminabative n,llies up to S5,000 per violation per day as described in Public Resources <br /> Code section 42962 i" (- <br /> PhP Q��Z ` -0)-25/ /2 I <br /> Drive 's Name(print) Div is Signature Date <br /> Comprehensive Trip .. • .. . Program <br /> i <br /> I " I <br /> a 42'5812 6 -_ C Pick up a Delivery III-N .[A-P.© a H a <br /> ompre <br /> FacilityTelephorie Number. <br /> Hauler Tire Program ID 1 Site Suffixj <br /> DATE ��� / �a %•�© KOH <br /> namm"H <br /> wWhole Tire Count 1:1 Weight in Lbs. . <br /> �- _ <br /> ne <br /> 11 2 . 0 1, ❑Volume Cubic Yds. Weight in Tons. s�� <br /> E "City,State 9,; S �tlG i <br /> �Ier Nam 3l0 / - 7 -1 ��i� <br /> Stamp or Lagel (/ D <br /> Hauler Telephone Number ( ■ Addre=m�a��auter Initials <br /> ^/ (NIA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> �"t� /G �!1 TC Who o Tires) AWS OF THE STATE OF CALIFORNIA THAT THE <br /> Last; C/C/ .INFORMA710N PROVIDED ABOVE Is TRUE AND CORRECT. <br /> I' <br /> Comprehensive • •• Number • • Information • <br /> 4 2 5 912 6 JB LJ'Pick Up Delivery <br /> d ® �� � �❑ <br /> Facility.Telephone Number <br /> Hauler Tire Program ID ! UR QZ <br /> DATE <br /> w' � Whole Tire Count Wei ht in Lbs:. SHE ®OEEm <br /> ®- ❑ g <br /> a� Facility Business <br /> d, El Volume Cubic Yds.❑WeighYin Tons NarrielAddreSs•o H alar am , --I. 'CuPyOL5tat4,eiid;( '� - ('5,�10�i63311533'as Hauler. IncoHaulerTelephone Numbe ❑- . <br /> 5� (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF TME <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE ' <br /> INFORMATION PROVIOEO ABOVE IS TRUE AND CORRECT. F0. <br /> ..r <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 1 <br /> 4259126 -- .A X Pick up. Delivery © � ❑ © �-.© 0 <br /> Hauler Tire Program ID I Site Suffix ®® ©© Facility Telephone Number <br /> comprel <br /> DATE- <br /> j ,c., w ®Whole Tire Count ❑Weight In Lbs. WhrXe, <br /> 2 Io 11Volume Cubic Yds.❑Weight in Tons ``a�AOdless- <br /> E, <br /> uler Name / a�:al r ZI J <br /> { C <br /> lu; �C?i SOS p A� S°^repor •a t/�j'*� n <br /> Q re 9►an1'e�s'Haule� Initial —J <br /> Hauler Telephone Number ■ LTJ <br /> /L I CERTIFY-THATUNDER PENALTY OF PERJURY OF THE <br /> (N IA Tires) <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> ho10 Tires] INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />