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Toll Free 1-866-896-06001 www.ciwmb.ca.gov/Tires/ <br /> CaliforniaIntegrated Waste Management Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA95812-1259 <br /> -"-"••• X- _ Comprehensiverum <br /> b <br /> er <br /> N3A <br /> I.3.., � 7 <br /> Sn�• ,C�f a� Q <br /> catua2oJflo;bs�INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE � .. w . <br /> By signing this CA Comprehensive Trip Log end Ft—ipl,the signar(s)requast that the Infoanation provided on this formwill be considered conrldenUal,proprietary and hadeaeerel.In aeeordanee with Title,14 CCR,Section <br /> 17041¢t seq.,If a requast is made for disclosure of Ihls Informatlon,the CN AIB will contacl the slgner(s)of this form el the address and telephone number provided on this forte or receipt <br /> Vehicle Information <br /> -- - _— — --------- — Hauler A <br /> Trucddress <br /> k Decal JUmbef` _ �j/t��,! rC{�l r'ft'r <br /> Business Name I r� f 'l / j't I��v <br /> �a R <br /> (: // I'D {, Address ) i4' t- 1.e; <br /> ❑1 City, State and Zip 1 <br /> Llcr�.inse Plate Number State (♦ <br /> 1 J 1 �� � i E � ��._ 1�.J.t:...•'N.=: ❑ Common <br /> t1 �L•:�C-Y..l 1. ��t�'� <br /> I cattily under pena'ry of p¢rury under the Is+ro of grg Stale of CaldorNa that the InfomwEon provided ebore Is We and correct In addition,t am effete that faisTF aeon of Ihls In om+atlorl may result In suspension,revocatbn,u denial of renewal of N <br /> Waste The Hauer RegsuaGon pursuant to Pubrc Resources Code aecGort 42900 and may result In rJv2 penalties up to S 25.000 par day,psr viofa;ion of adriitrlisUaFyre pena'des up W§5,000 par violation per day as described in Pub""c Resources <br /> Code section 42962 / ` �) f.J.•/ <br /> Driver's Name rint " /v Drivee s'Sig`n`ature Date <br /> Comprehensive Trip Log • Program <br /> 3248870 �� f u � oaaaaaa�m� <br /> x � <br /> IN <br /> Mj <br /> Hauler Tire Program ID / SiteSuffix <br /> Facility Telephone Number <br /> H 2 LP <br /> LL[ ❑ V`1101e rite Couht Ule[clfit In t_U5 <br /> l'ii, i- n Ills r ^iIJotiTC <br /> (� d -1 t 1, �� ) ' Vofulltc Cllbt .Ycis C .reigltf 4h'fon !� tl„ 1/�rldln ) <br /> ;At,. .,t:ate.and til; <br /> 13 <br /> Hat er Marne - <br /> /t; . <br /> e, ,r T, ❑ Address Same as Hauler rnrnars"'" <br /> I-la(tler elephone Number -_-t <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> 1 <br /> LAWS <br /> FORMA ON PROVIOED AaOVE IS <br /> IE <br /> INRU AND CORRECT. <br /> Comprehensive Trip Log Number • • InformationProgram <br /> n ` elu.324B87 ry ❑ j' i` ® () a <br /> n Hauler"tire Program ID t Site Suffix T- 1 Facility Telephone Number <br /> oA, < a <br /> ❑� r 1.i <br /> t - �� Haooaa ® <br /> w �, Vin w,Iw C't7ttra Xe-i ttin t_I <br /> vN 4 4 } -;A Il ty BlAines �I <br /> 3� ue C lbs lI j5 ti Irttatffi Fart !Jb ?IYC3irt"> <br /> i:ftr :it:3lt3 Tttl r�l) /i <br /> Hauler Name - <br /> ii iA <br /> _ <br /> .:,rai�tlr^�r•�3'rtc?i.i7{ <br /> { <br /> Haul Telephone Number Address Same as Hauler Initials. ` <br /> I CERTWY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CAUFORRIA THAT THE l <br /> 1 <br /> I <br /> •mprehensive Trip Log Number •.• Information Facility Tire Program ID Site Suffixl <br /> 3248870 �- f<� p►�I{ Up <br /> Hauler Tire Program ID ! Site Suffix facility Telephone Number <br /> nc, a-�aoa000 <br /> _ I <br /> f <br /> 'HaulerNlite <br /> t/ <br /> Number z .,. ❑ Address Same as Hauler rnitrars <br /> hauler Telephone r <br /> _ N I CERnFYTHAT UNOER PENALTY OF PERJURY OF THE <br /> r i i�7 f�• . r" / ..�..r. r ewe ne•ue tti..a..e P.,,rno,n."....ve i / <br />