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Toll Fre61=866=896` 600 l www.ciwmb 'ca goy7Tires/ <br /> ment Board <br /> CA Comprehensive Tri ptog and Receipts 10002 C•Ittornlalnt59,aa:dWastt6,CA6e812-1259 <br /> P.O.Box 1259,Sacramento,CA 95612—12b9 <br /> •�. ,�, EX AfiM P. 1 2 3 rehenslve TripNumber <br /> OW-iso {. <br /> cnwatw(roos)INSTRUCTIONS ON BACK OF PART 2' DO fVOT LfAPSa STAPLE OR n' <br /> By signing this CA Comprehensive Trip Log and Racelpt,the signer(s)request that the Information provided on this form wig be considered eonNdanUal,Proprietary and tradesecrat.Insecordancowith7ide,14CCRSecuon <br /> 17041 at seq-.Us request Is made for disclosure of this Information,the CMMB will contact the algnor(s)of this format Mt address and telaphome number Pro ttded en Ibis form or(acelPL <br /> HhtilerAddress `, 7, , . O . e`� ,^Ic TF <br /> Business NAme <br /> "Address j <br /> City, State and Zip <br /> QCo.man <br /> I certy under penally of perjury under the Iarrs of the Stave of CegforNa that the In!ermatfon Provided above Is We and C.Mect In owlfon,I am Ih falsibeaGon of MIs kdarmaCon may restat In auspans?on,revuCa6on,or dsnzl of renewal of <br /> Waste Tire Hauer Reg?stralion pursuant to Public Rssources Code seccon 42960 and may result In ch0 penaffies up b$26,000 per day,parvlotayom 'nlstra6ve Penalties up to 55,000 per vloiabon perday as described In Public Resources <br /> Coda section 42062 rp .:i. .r.. .! = . .. / "3 <br /> Driver's Name ant Date <br /> • <br /> prehensive Trip Log Number Load Information Facility Tire Program <br /> CMilln <br /> 3248736 -- <br /> 1� <br /> NNEN <br /> Hauler Tire Program ID ! Site Suffix I J.� Facility Telephone Number <br /> © ea 0 ':':H H D P 0 P) <br /> 1 acil �yliRess tJi .l•, 4�c� <br /> 4 C> <br /> City $ <br /> Hauler Name <br /> L <br /> Stv)1nr �r�tiltlll�, G1 t <br /> Haufer 7`elephone Nu tie" :.�� :..i:° Q Addt'ess Same as kiau tar mmars <br /> I CERTIFY THAT UNOER PENALTY OF PERJURY OF THE <br /> e <br /> CJ•i, `-� '' LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> -tNFo ROVIDED ABOVE W TRUE AN <br /> 0 CORRECf. <br /> 3248736 <br /> Hauler Tire Program ID / Site Suffix �~ Facility Telephone,Numb.6,.. <br /> ORB:: o a o <br /> Facilit�Bushtess <br /> .1 G •bas l Namod$w s <br /> City,Sta#e anc3 Zip <br /> Hauler Name � � fN e <br /> /, . ( �. <br /> l)!� ✓ �� j�'�(-� $ Stamp or�ltLatityt �I <br /> AddrewSMelas HI�11 B Wars <br /> Hauler 1"elephone Number <br /> CERTIFY TItAT UNDER PENALTY Of PERJURY OF THE J / <br /> LAWS OF THE STATE OF CAIJFORNIA THAT THE f .E-7 <br /> E CORRECT. �.11...((;.!.. . <br /> 3248736 <br /> Hauler Tire Program ID t site suffix Facility h <br /> Te 8 ono Number <br /> I .p.. . <br /> ADDa o00 <br /> 0 <br /> ell! u ) ass > <br /> �, �) ( at•Iw lj r PJafiiefABles� ff <br /> Hauler Name _ Cit stat ndi <br /> PAt•J Stam a <br /> 1-lacier Telephone Number �1/ �5mSe(as Haug , <br /> _ :I CERTIFY LNAT UNOER PENALTY OF PERNAy:oF THE ; <br /> . -w 1 ,.,..e..a,.ra e,aTC r.e r.r.er.s.m.4 <br />