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Toll Fret .=866=896-0600 /www.ciwmb.ca. ovil ires/ <br /> •••• -` ' Califomla Integrated Waste f lana emnt Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.C.Boz 1259,Sacramento CA 9581 2-1259 <br /> � e: X A M P >r 1 E 3 <br /> com rehensive Tri Number <br /> crwirela7 `INSTRUCTIONS ON BACK OF PART 2' DO IJ07'TAPE STAPLE OR Dt1PLICA7E w �` <br /> By signing this CA Comprehansly Trip log and RectIA the slgner(s)request Nat the Information provided on Ills form wir be considered eonllden0al,propd•tary and trade-IaL N iccorda�cs+�TUr T'itte,14 CCR,Sacuon <br /> 17041 et seq.,Ita request is made for disclosure of this lnrormallon,the CN/MB will contactthasignet(s)or Nts format the address and l•lephone number provided on this form orrecempL - <br /> hauler Address � <br /> 'Business Name Gm fl i. v!-� r. lu <br /> t t. Address Gl <br /> �'. `y' <br /> City, State and Zip <br /> JCommon <br /> Carrier.., <br /> - I certify under penalty of peduty under the Laws of the State of Carfomfa that the information piomed above Is bu•and aoeect W WCAon,I am a vers Nathts. Gen of Vents inWrma6on,huy raswY to awpon mn;woca on,orEanlel of rcrievrel of N <br /> Wasle Tire Hauler RaQZsbation pursuant to PuMc Resources Code sftNn 42980 and may result In&.1 persalCes up b S.25!00?per day,per vWfor adm6ds"ItI I!n flea W l0 35,000 per!Matlon per day as descrbed In Pubic Resources <br /> Code section 42982 `„',, <br /> 6 r <br /> Dr errs Name(print) :: ...... D lv_e�'. Sl9a u.e. : ,Date .:. <br /> • . <br /> 3 . •aC <br /> • <br /> 78 <br /> Hauler Tire Program ID ! Site Suffix <br /> . F0oaFcil�it'y�TaeLuleJ:pi�h0�os.sn. <br /> e Number <br /> ysac <br /> �s A a <br /> aaQ <br /> saaa <br /> Na; <br /> el <br /> Hauler Name <br /> 1 f� ri !1 �7 `a 3 s tlf <br /> Hauler Telephone Number ;» 'Addre$s Same as.Hauler rnrlrara J <br /> 1 CERTIFY THAT UNDER PENALTY OP PERJURY OF THE <br /> 2•(� LAWS OF THE STATE OF CAUFORNIA THAT THE C./ <br /> OH RO OED <br /> (E 13 T V AHb <br /> • a a • • • • • <br /> 324871 :8B 0 0 M '1 <br /> Hauler Tire Program ID / Site Suffix F4cili Y Telephone.Nutnber <br /> 000-aoQ � © oa <br /> bac•ilty t3usiness } ) <br /> .o ? A :� s Na �1(Fjri 'rd,13 <br /> Hauler Nam City,, tit and iq- ea <br /> i `� ..�tc'Tt'p rj 1. '� t�.�,i C..,C`Jt 7 U) -JJFl <br /> Ades§Same as.Hauler rmrfrars <br /> Hauler T lophone Number <br /> \ J I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CAUFORNUI THAT THE ,fy <br /> tNFO MATION PROVIDED ASOVE 18 TRUE AND C ECT. <br /> • . • • • • a r1l Un • <br /> 3248718 ®® ID► <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> I lCltSlYpt YID L'� w 1 Vic <br /> r c rens <br /> Hauler Name <br /> Cit tiir� <br /> PA Stamlq plil d 04( C(Y <br /> `^ 7 <br /> Hauler Telephone Number L Address same as Hauler rnraars <br /> 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> �� �•� aT L”"'� J '� EAWS OF THE STATE OF CAUFORHU THAT THE AL - <br />