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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 /> EIIX a�nnP L E{ i 2 3 <br /> �, Comprehensive Tri Number <br /> cmx=(Iwiw.s INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE 425912 <br /> By signing this CA Comprehensive Trip Lop and Rscelpt,the signals)request that the Information provided on this fort will be considered confidential,proprietary and trade secrat.In accordance with Title,14 CCR,Section <br /> 17041 at seq.,If a request Is muds for disclosure of this Information,the CINNMB wla c Iact the signals)of this form at the address and telephone number provided on this form or receipt <br /> VetiOW11nforination <br /> Truck Decal Number Hauler AddreSS <br /> F <br /> Business NameAddress <br /> 2 ��PS L� C�Ij i�n�f <br /> City, State and Zip yds, <br /> License Plate Number State c� / <br /> C ❑ Carrie on C �4 9V�/ ! . <br /> 0 ® © ❑ H® ® ❑ � <br /> cwtfy under penalty of perjury under ths laws of thpp Slate of Catfomta that ale information provided above is We and cones.in addition,I em aware that falsification of 0y's information may result in suspension•revocation,or denial of rene•,al of th <br /> Waste Tire Hauler Regis rwant to Public Fwurces Code section 42%0 and may resufl in dvil penalties up to S 25,000 per day.per vio adminishelive pgrallies up to$5,000 per violation per day as described in Public Resources <br /> Cade section 42902 (//—,,/� <br /> a � 1 ? it t .7-(l 7 t k: 1 11l <br /> Drivers Name(print) Dri er's Signature Date <br /> Comprehensive Trip . . Number Load Information Facility Tire Program <br /> 4 2,5-91'2 4 . -- C Pick Up Delivery ® �—©j 0 <br /> ® ❑ o ® oa ® <br /> rHaulerTeh <br /> ire Program ID 1 Site Suffix _ Facility Telephone Number ' <br /> •DATE <br /> � wa_® Whole Tire Count.�Weight In Lbs.. _ - <br /> �Cility Business ". <br /> �Ljler <br /> ElVolume Cubic.Yds:El-Weight in.Tons Name/f 11hAYO TIRES AUTO REPAIR <br /> City,fj8b <CON'NECTICUT ST.,STE. 11 <br /> o H Nam - <br /> n r JJ HAYWARD,CA 94545 <br /> ci 2 /c7pS 4° �- Stamp or Label DK <br /> a ❑ Address Same as Hauler Initials ` <br /> Hauler Telephone Number . <br /> (N/A for 1 CERTIFY UNDER PENALTY PERJURY THE I <br /> (yJ( G (yfr �J` Whole LAWS$OF THEHE STATE OF CALIFORNIANTHAT THE <br /> Tirest <br /> INFORMATION PROVIDED ABOVE <br /> 15TRUEAND CORRECT. <br /> 1 <br /> Comprehensive • •• Number • • Information 11 <br /> Site Suffix <br /> jHaL <br /> 25.9,124 .,-- B R.Pick-Up Delivery �. POE\�—© <br /> Tire Program ID I Site Suffix Facility Telephone Number . <br /> DATE <br /> in Lbs.Lu 7�Whole Tire Count Weight F acil 1(s.nes 7,I 31 - Q` `; .a Volume Cubic YdsEWeight in Tons A'.r.ate, dd t ss.r Name -C11j /7°S C g sat. r 1 �1 /510 J <br /> :Y 1 <br /> Hauler-Telephone Number �/ A d s ame as Hauler- mrtrat9" l <br /> (N lA fOT 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 /> f, <br /> 42-59IZ4 A . Pick Up, .� Delivery <br /> 4, Hauler Tire Program ID''l Site Suffix �© Facility Telephone Number <br /> y; DATE ®© / I <br /> aa �- � a� <br /> tv. <br /> Lu ©.Whole Tire Count Weight In Lbs. . <br /> -•,. � / Facility Business <br /> d 2 I a ( Volume Cubic Yds. Weight in Tons Name'"��'oG� <br /> D ❑ . oaband.Scra ,LLC <br /> E tiler Nam City'cw6_V �'R! &ue Suite 4 <br /> f y Stam Oakland, 'CA 8421 <br /> a ( 10 633 1533 <br /> Hauler Telephone Number. ❑ Aar ss same as Hauler intfto <br /> i 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> (N IA// ) 2 T for LAWS OF THE STATE OF CALIFORNIA THAT THE' - 1 <br /> Whose <br /> ✓✓✓ l./ fff INFORMA THm PROVIDED ABOVE 19 TRUE AND CORRECT. <br /> \ w / <br />