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Toll Free 9-866-896-Q600 /viww.ciwmb.cti.gov/Tires/ <br /> CaNfoinla Integrated Wasteldanagemenl Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Boz 1259,Sacramanto,CA95812-1259 <br /> S <br /> AAh Com 'rehen ive Tri Number <br /> 4n7am3➢f r <br /> h B' a 8 <br /> crrra � 1oa+'s11NSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE <br /> By signing this CA Comprehensive Trip Log and Receipt,the signer(s)request that the Information provided on this form will be considered confidential,proprietary and trade secret.In accordance with Title,14 CCR,Section <br /> 17041 at seq.,It a request Is made for disclosufs of this Information,the CIWMB will contact the signer(s)of this form at the address and telephone number provided on this to"or raceipl <br /> Hauler'Address �- <br /> Business Name <br /> Z Address `,�. Cl <br /> City, State and Zip / <br /> b 7F1Carrier op y <br /> I cedify under penally of perjury under the lass of Ike Slave of CaVomla that the Information prw'dod above is We and correct.In edition,I am aware that falskf�4 of this inforrnafon may rVsut in suspension,revc-a.,or lenlal of re awal of <br /> Waste Two Hateer Regisha6on pursuant to Public Resources Code section 42960 and may result In cM pen_a'ties Up to 5 25,000 pair day.Per vlefa^*n or�.nfslra[hepg�[es up m$5 D00 per vlolaLon per day as desr�bed In P. <br /> Resources <br /> Code section 42962 <br /> � � <br /> tet) �.--..e..,.._ C3 <br /> Driver�`s Name(print) Driver. : icfnature ate' <br /> •• •- •. • • • 8=4 <br /> 3248862 -- ® G� 0 <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> Qua-aa0000 <br /> I' " k 'Bu Smes! <br /> Hauler N le <br /> Si 11 1'QOtt;I_ A` C <br /> Hauler Telephone Number Address Same a Nauler Initials <br /> r l 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE r t <br /> INFORMII 0 PROVIDED ABOVE IS TRUE AND CORRECT. \\+-- <br /> 3248862 <br /> Hauler Tire Program ID ! site Suffix _ l Facility,Telephone Number' <br /> Qa co�ooa <br /> 1/ Fa ty txilsiness <br /> �)( oet U—fik � <br /> alder N e <br /> Hauler Telephone Number <br /> Address Same fHaulsInl(lal's <br /> _ I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> `�J LAWS OF THE STATE OF CALIFORNIA-171W THE <br /> `� �'/ !.. IHFORMATIOH PROVIDED ABOVE IS TRUE AHD COWiECT. <br /> n <br /> 3248862 -- A :. rMyHauler Tire Program ID 1 SiteSuffixTelephone Number, <br /> _. Qoa-®oo3a ® ao <br /> Fa 1k �ineser �t <br /> Hauler ame �� ( j anti����-'(—c\c( i <br /> —or 6V r GEV g S 3 3 '�- <br /> Hauler Telephone Number ' Q Address Same as Hauler mrrrats <br /> 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE i <br />