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• <br /> I <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT- <br /> Comprehensive <br /> ORRECT. <br /> • • • Log Number Load Informationility • <br /> gram ID Site SUff iX <br /> a15L,� 8•C�g B ,' Pick Up LlDelivery ❑ 0 �i <br /> v Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix DATE yj' ❑ ❑ ❑ '�j <br /> LU a Whole Tire Count Weight in Lbs. <br /> a �r�. r�irta�c� <br /> ,." rJ i I 0 Volume Cubic Yds:❑Weight in Tons '!5F!1ttr4lilrt„� <br /> � <br /> o Hatilor Marne 1.:tl%,{j <br /> ` EOEEE'H GanT<; <br /> Fiatdnr'felehhl,rte Nunther <br /> . (N/A for - I CERTIFY THAT UNDER PENALLY OF PERJURY OF THE <br /> Mule Tires) LAWS OFTHE STATE OF CALIFORNIA THATTA: t �, <br /> INFORMATIONPROVICZ. ; ;'EAMB_00M.T <br /> CA Comprehensive Trip`Log and Receipts 10002 `P:o:'aax'�= s��+ + S81z=1zsg <br /> rehensive Trip Number <br /> �BBBBBBB � Com <br /> �..� � � _- ,, . 3248639 K :.,.. <br /> a""'"""""e INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE <br /> c1wMe m9 paF� <br /> By al0ning this CA Comprehenslve Trlp Log and R.celpl,the elgne,la)nquaal that the if—.11-pFov(d.d oo ON.Io ne.1111 be eondd•nd eanMmHel pmp,lotary and trade a....l.In act ardente with Till*,11 CCR,NeNpn <br /> 17011 at seq.,N•squeal b mad.for disclosure of Ihls Inrarmell.n,the CIWMS will cnnled the.)goer(.)el thle term al the add,...and l.I.,h—number provldetl on Ws torts or lacefpl <br /> Venic e n otmat on Hauler Address <br /> Truck Decal Number Business Name �'�� 'r Pz L � � f.'�`M . <br /> Address <br /> ❑_ 7 i i' l <br /> City, State and Zip c- � • ,� <br /> License Plate Number State f �, _. [ y i',7 <br /> 0 0 0 0 [10 0o r{o�on <br /> I certify under Penalty of p.qury under V,a lawa o!the Stale of CalibrMa mat IM Inlartna0on provMed above H Wa and carted In addition,1 ern aura MN 4lyfeN wat Fda 4donmMan mayn in au"nelrb rav tion,ar denial of renewal of th <br /> Waata <br /> Ty-PH suter Reglstralion pu UMI b Public Reaoarcoa Cod.section 12960 end may re%uX In cMI penalties up Io S 25.000 pe,day,par y1oMEart o�aAmIMTYj/Mbenalba up 1.16,000 pr. &Von per day da dbad In PWIe Ratowco. <br /> Code eecllon 429 F2 - +. . `• z ,�,.. r,(^ y �.;� <br /> �,,r . <br /> Drivers Name tint ,-Drivaf s Signature Date <br /> Comprehensive Tr • Log Numbera.• • • Program <br /> P .❑ Delivery ❑ ❑ a00-o r <br /> 3248639 -- C '� Pick:U <br /> v Facility Telephone Number <br /> Hauler The Program ID I Site Suffix DATE ❑❑ % ,❑❑ r ❑ r <br /> v, <br /> , <br /> 000- �� o �t� oa � 0 <br /> MI W/ WholeTlre Count Weight:In Lbs.` I u taitlr ne:,.M. <br /> ) <br /> /., ;l / �_ r.> r ❑`Volume Cubds.❑Weight]n Tons <br /> �• <br /> 1tFi §`srl <br /> g Hauler NamoL� <br /> Address Same as lintrier I�rrraafs�. <br /> I - I <br /> Hauler Telephone Number n- 001A,"H10 <br /> - I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> F - ... .• .y r •«. - .-�N IA,far LAWs OF THE STATE OF CALIFORNIA THAT THE <br /> Comprehensive Log Load Information Facility Tire Program ID Site Suffix <br /> Pick Up <br /> Delivery; � .- -� r"? ❑—❑� � <br /> 3248662 ❑ <br /> Facility Telephone Number <br /> a Hauler Tire Program ID 1 Site Suffix ±❑ ❑❑ ' — <br /> El :;tL le T r : un} ❑ <br /> I0iC+ fltl1 ,,. „� <br /> Ita�dy.�d i�.(C'y"l."� �`([�Jl. <br /> Hauler Namej I / { t �� <br /> At <br /> 4Sit I car Lte r < <br /> . ;,..� ❑ Address Sanie as Hauler initials <br /> I auler Telephone Number ICERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE IN CALIFORNIA THAT THE <br /> INFORMATION ROVIDED ABOVE IE TRUE ANOCORRECT. ^.�•-` <br /> y`- <br />