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x <br /> 4596031 B Pick Up Delivery 0 0- <br /> U <br /> U <br /> Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix DATE <br /> 'c w Whole Tire Count Weight in Lbs. <br /> Volume Cubic Yds.D Weight in Tons <br /> LC6 6�3-j 17�- <br /> sn,das <br /> (N/A for 1 EENTiFY THAT UMEA KNALTY OF PERAINY"-E <br /> Whole T%Q i Aw OF THE STATE Or CAOFOlomm THAT THE SLQ. <br /> arFONWTAN NNWIOFO A.WE 1a T-E ANO CONNECT. <br /> California Integrated Wada Management eaard <br /> CA Comprehensive Trip Log and Receipts <br /> 10002 P. Box,259,Sacramento,CA96012-,249 <br /> FXaMP L it <br /> S Com rehensive Tri Number <br /> (�-_�-i_____i_..�5�2 �I 3248699 . <br /> - <br /> cnvMe:9,11aD5I INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE <br /> By+I9n1n9 thl.CA Compnhan.IVe Trip Lop and Receipt.the•lynx,(.(,•qua al that the Information proal an 11,11form wlll ba eonald—d aonOd-11-14 prapd.lary and trach secret.In acaordane•with Till..14 CCR,9.01.. <br /> 17041 at seq.,If a r•qu+.l 1•mad.for diedH.....01 lhInformation,the CIWMR.111 contact the alone,(.)a(this forth al the+ddn.a and telephone number provided on this form or reulpl. <br /> Vehicle Information Hauler Address _ - yy <br /> Trunk Decal Number �l�y ��` 1,,frn j <br /> Business Name <br /> r R �",� 00, City, State and ZipAddress d u d <br /> ' �' ' �S <br /> Llcense Plate'�Number State 9Lv- <br /> C <br /> C1, `qC <br /> Gun-to(.0 0a [105 <br /> I unity ender Penalty or perjury under the laws of the Slat-of C.0fomi.NN N.Information pmNd-d.lww N W.end—t.In ddNl-.I am..are that falsification Of In Is Information may m.Wl In-usen <br /> Psion,re—oflor%m denial of renewal of N„ <br /> Weal•Tiro H.u1er Re9latiiilon p—...l to Pudic Resources Coda eaclbn 42900 and may haul 11 clod penalties up to S 25,000 per day,per Violation a adrnini;U tNo penalties up to$5,000 per VIClalbn par day aE d—Abad In Pubfo Resources <br /> Code...tion 42962M ti <br /> Driver's Name print) J vrivri er-WSlgnature ale <br /> Comprehensive • Load • • <br /> n Facility Tire Program ID Site Suffix <br /> \/ Plck`Up Delivery � _a) I <br /> -- <br /> 3248699 C 0 0 0 LfJ �- of <br /> yFacility <br /> Telephone Number <br /> . Hauler The Program ID ! Site Suffix <br /> DATE' <br /> c 011 1 <br /> w 110 Thu <br /> The Got liuelght In L,bs t <br /> l�yr <br /> Vdlume'¢ut�tc,Yde ®Wel®ht In Tong "' <br /> tacIM . <br /> _> f k' <br /> U' F �/i f eJ Lr ' <br /> d "� ,■ f /address SarA as Mauler r <br /> Hz war i elophone Nunihor I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE (� t <br /> <� ,'•WhOlik for Pa 7iPe SJ: twWi of THE STATE OF CALIFORNIA THAT THE _ s <br /> INFORMATION PROVIDED ABOVE 13 TROs ANO CORRECT. , <br />