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Toil Free 1-866 896-0600 -i www:ciwrnb:ca:gov/Tires/ <br /> t Cal)fbrnit6 Infag6 elf►Neste Management Board <br /> CA Comprehensive Tr' Log and Receipts 10002 RO:Bti'x1259, acr'Jimentd,CA958S2-1259 <br /> { . . <br /> Comprehensive Tri Number <br /> ' E `X A M P 'L 1 2 5. -� v w <br /> alvuemi INSTRUCTIONS ON BACK OF PART 2 'DO NOT*40E, STAPLE OR DUPLICATE <br /> By signing this CA Comprohenslw Trip Log and Receipt,the slgn•ri[s)request that the Information prodded on this form will be considered confidential,proprietary and trade secret In accordance with Title,14 CCR,ssctlon <br /> 17031 at seq.,It a request is mads for disclosure of this Information,the CtWMB will contact the slgner(s)of this form at the address end pfephone number prodded on this form of recelpt <br /> Hauler Address <br /> Business Nar'r)e <br /> 1 `( t� Address <br /> City, State and Zip p <br /> I m&ty tmdar pe f a'ty of parjury under the lass of the State of Ca`foWa that LFA Information provtcled above is true and coned In addition,I ant aware t falsifkadon of Ods Inbmistipn may rest �suspigaton,rovocal on(or denlal of rens•,ral o'6i:. <br /> Wase T"Hainer Reg'stra6on pursuant to PubFc Resources Code se 5"42960 and may resell M ctdd psnalfes up to$25,000 per day,par vwaton or admMlstraHsn) alBes up to§5,000 per vWatloo per day as deserted in Public Resources <br /> Codes Vc 42962 1 �� , �� •:! - r. <br /> It <br /> �"r(ver's Name(print :r:r•rr r': tgnature t Date <br /> RMt <br /> 3248710 -� ':,_ D0' `� RPH7RE <br /> Hauler Tire Program.D 1 Site Suffix ;;aa aCiiity Telephone Number <br /> t <br /> dell iity Bushi,ess <br /> ( p 2 7 3 (` lathe <br /> Halder t4ame <br /> t ,- afiC <br /> Hauler Telephone Number ;+;': <br /> ❑ Address.Same as.Hau.ter 7•f1 <br /> (A r I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> c <br /> 1 �, LAWS OF THE STATE OF CALJFORNIA THAT THE <br /> / 'MFORMATION PROVIDED TRUE AND CORRECT. <br /> 3248710 B DOB 0 � ;0 0 :0 0 <br /> Hauler Tire Program ID 1 Site Suffix Facility Telephone Number <br /> • ,7 a-a aoc� ao -� a <br /> I� : pacilit�usI ss <br /> Name=? <br /> ' 'City,L`- a Arid Zip <br /> Hauler Name >= f � 1 f,(.;�.✓:St4..S' <br /> k ( )` <br /> Stamp gaai e, ri j�sj <br /> Hauler Telephone Number / Address Same as Hauler 7ffa7s —I <br /> 4_ I CERTIFY THAT UIEDER pENA1TY OF PER' R'TILY.OF THE s <br /> NWS OF THE STATE bF CALIFORNIA THAT E ' r( <br /> PROVIDED ABOVE 121RUE AND CORRECT. <br /> 3248710 -- A <br /> Hauler Tire Program ID ! Site Suffix Facility Telephone Number <br /> � oo�ooQ � aaa <br /> Fa0'!q0UCSM <br /> NaI C.n11:' <br /> � <br /> = <br /> Ci+ , t to anUlp <br /> HaLiler Name Jr `re�' #' <br /> �Y lk ptddfajtA rre as uT S�.3 <br /> Hauler Telephone Number ❑ :�-:�-•:-._: , <br /> al . <br /> ..» 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF y,,� <br />