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Toll Free 1-8M,8960600 / www.ciwmb'-ca.'clov/Tires/ <br /> California lntegratod Waste Management Board <br /> CA Comprehensive Trip Log and Recell s 10002 ).Buz,259,§acramelilo,CA95812-1259 <br /> 1XIA! Met 1f .3 Com rehensiveTri Number <br /> swf orc-alw NUN3 <br /> cnYuesoaowv INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE <br /> O <br /> h R IDUPLICA7E - <br /> By signing this CA Comprehensive Trip Log and Receipt,the signer(s)request that the InfomvUon provided on this form will be Considered conftdintial,proprietary and trade secret In accordance wish Title,l4 CCR.Section <br /> 17041 at seq,If a request is made for disclosure of thl!information,the CAYMB will contact the signer(s)of this form at the address and telephone number provided on this form or reeelpt <br /> r' t3 1.Gl.e tIIIIJ, <br /> Hauler Address <br /> Susi6ess Name ���j �;!ti:� t d'(f �. <br /> rr fJ t . <br /> - I` lyt Address <br /> City, State and Zip �0 o <br /> 0 <br /> 1 carGy under puutty o`t perjwy undu Me laws of the State of CaT!am+a that Ds Intormadon prcJded above b Wa and sorest In•ddOfon,1>).1'n•,-(va{e Drat fa Cm d Ods bdomsa°on msy resVlt Yt suspens!ori.rewcation,or denial of ren"-al or 111 <br /> Ylasta Tas Fiav!er Registration pursuant b Public Resourrxs Coda section 42960 and may teswk in oFi penal0es tp l0;25,OOD,per day. 'r vto5p6ott or•drlthllsbadv?p•nafCes W to;5.000 per vbation perday as desrnted in Pubffo Resources <br /> Dr. er's Name{print _ der.'s S1g,attire.. Date v <br /> 32488`98 -- ► c ® ;; ( ���. � ' <br /> aao <br /> Hauler Tire Program ID / Site Suffix Facility Telephpne Number <br /> i k <br /> t <br /> t f <br /> a <br /> � at•:o©ooaao <br /> tlPess <br /> Hauler Name <br /> L <br /> it t/Zlbt ?y 9 5 <br /> ddress Same as Hauler <br /> Hauler Tele�fione Number Arnruar <br /> I <br /> CERTIFY THAT UNDFR PENALTY OF PERJURY OF THE <br /> + G 1 Cc LAWS OF THE STATE OF CALWORNU THATTNE < .. <br /> `r J J; <br /> INFO RMA PROVIDED ASO E CO CT. <br /> • • • •f f • • a • • 1 <br /> 324889 <br /> r. Facility 1'efeppone.N.utnber <br /> Hauler Tire Program ID 1 Site Suffix,;. <br /> ^C1 Baa-aoa � aoo <br /> Facili usi'e � r '• ' •' 1 <br /> city, tate acid Zip /`•/ <br /> Hauler Name �. 0.0 , (5 ✓� l/- <br /> f�1 1 �taml)0 � OKI <br /> 2.> iv > <br /> Hauler elephone Number Address San as at er nitials <br /> 1 CERTIFY THAT UNDER PENALTY OF PERJtiRY OF THE <br /> LAWS OF.THe STATE OF CALIFORNIA THAT THE <br /> 1 FDRMTION PROVIDED ABOVE 15 TRUE AND CORRECT. f <br /> • f • •f ! f • <br /> a. • a . <br /> 3248898 -- A o << o © o a s <br /> Hauler Tire Program It) ! Site Suffix Facility Telephone Number <br /> oof� _�ao 000 <br /> Fac► 1rsi�e�sr �> ��)�y�f <br /> a <br /> o l Nan ddress <br /> uU1. U � <br /> Hauler Name �rld A <br /> Stamm LAP OI< C <br /> C�AddW4 SaWafi-Hauler� nmars <br /> - I <br /> Hauler elephone Number <br /> I THAT UNDER PENALTY OF PERJURY OF THE - <br /> � _ /•_ ! _ . i i lWQ rti TNF RTaTF f1F r:l11FnRNle 71r1T TRF / .'�`�~ <br />