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Toll Free 1=866-896-Q6001 www.ciwmb.bA gov/Tires1 <br /> ', � ` '�' "�'Cali/omia In4egrated Wasle`6lanagement Board <br /> CA Com rehenslve Trip Lo and Recel is X0002 Po.eo=,zsg Sat arrientD,lAe6g12_,2s9 <br /> p p g p' Comore_ hensiveTri _Number <br /> ■u ef"tfetDs INSTRi1CTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE Ol;t Dl1PLICA"I :�..0.1". <br /> n <br /> By signing this CAComptabensiee Trip log and Receipt,the slgner(s)request that the Information provided on this form wig be considered confidential,proprietary and bads secret.in aKordanco with Tide,14 CCR,SscUon <br /> 17041 at seq.,if a request Is made for disclosure of this Information,the CNIMB rill contact the slgner(s)of this format the add resa arA telephone number provided on this form errscofpt.- <br /> _' ix`�Billc a]nfglf�►a n�:i :4-�a r<r��;,�,.� <br /> G''�' r t <br /> Hauler Address � <br /> �' "{ <br /> Business Name <br /> .,.f'T`' �,,N <br /> . . <br /> Address (` <br /> City, State and Zip jl) <br /> j 1.( � Gomnioli. , .�. � �:�.1 C...-';�'.e ;�D l✓° �J �r'� <br /> I certify under penalty of penury tarda the fans of Ue Stale o1 Ca[forNa tiut Ne Wonnation Provided shove Is W e and canatl In ad�Cdn i am aaera Uut Iatslfca' inforrnaEon may reewl M auspens!ary rc,'epUen,or dPubf of Resources Wase Tire Hauer Reglstraeon pursuant b Wb5c Resources Coda sectbn 42960 and may result M dv7 penalties tq b S 25000 per dey,per viola0on or av up lo 55.000 per vldaPan per day as deacdbed H PubSn Resources <br /> Driver's Name rint ,D ve"r ...gnafure,':, .;!t,::,;i at <br /> • • •• • . M- 11MI <br /> 32488810:00 0 -� <br /> Hauler Tire Program ID / Site Suffix i Facility Telephone Number <br /> 10 10 Z t4,, (r <br /> Hau m <br /> C t l V Stamp or,121�e1.PK. <br /> Hauler Telephone Number = Q Address Same as,:Hauier liars <br /> 1- r jr <br /> Aws orf THATUNDER CAEJFYNL PERJURYOFTHE W ,. <br /> LAW9 OF THE STATE OF CALIFORNG THAT THE <br /> INFORANATION PROVIDED ABOVE Ii TRUE AND CORRECT.. <br /> • • a •t • •, • • e • <br /> 3_2. 48881 <br /> Hauler Tire Program ID ( Site Suffix ;;',. Facility.Telephorle NUinber. <br /> aao oaooaoa <br /> Fa 11n4e,s�o ,1'/ <br /> 2 l, _1 — I'fLsllokl3 <br /> Hauler.Name It a'e <br /> Hau er Teleho)e Number Address Same as Hauler (vats <br /> i CERTIF-Y THAT UNDER PENALTY OF PERJURY OF THE <br /> -' LAWS OF THE STATE OF.CALIFORNIA THAT THE <br /> Ko F N PROVIDED AND CORRECT. - <br /> • • a <br /> MOP 101 IUM• •.• a • e • <br /> i <br /> I <br /> 3248881 -- A ,o <br /> Hauler Tire Program ID 1 Site Suffix ty.Te hone Number <br /> :$ g o-a 0 0 <br /> 0­1 <br /> � V-dll'rie <br /> •� ► <br /> Hauler Name "l� a iPf, j 0�� <�/} <br /> p or Label OK. <br /> Hauler Telephone NumberAddress Same as Hauler initials <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE ! <br />