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Californlo Integrated Wasto Management Board I
<br /> Log and Receipts 10002 p.o.Box 1259,Sacramento,CA 95812-1259
<br /> Com rehensive Trip Number
<br /> 7.
<br /> IT 2 DO NOT TAPE STAPLE OR DUPLICATE 3 2 486 9
<br /> tel the Inlormellon provided on thin form will be eonaldered--flar ",proprl.a y and trade ncT•L In accordant.with Till.,14 CCR,Becllon
<br /> will canbcl th•slgner(aI of this form al the addre.a and w.phone numbar p,.Ad.d on this tong W teo.ipl.
<br /> Hauler Address
<br /> Business Name /,7,r
<br /> City,Stess
<br /> Zip d'2 0 -30
<br /> n Comriion
<br /> I—I Carrier
<br /> —0cm provided above Is We and coroct.In eddilbn.I am awtes that fatsglcation of We Wlmmatbn may ruin In suspemlon,lav tlon,or d_"of r.nawal or lh
<br /> nd may result In dire pe sill..up Io S 25,000 par day,per vlaladon or oda tylrafjve penNB"to SS,DOO par violation par day as deacnbad In Pubee Resources
<br /> "tirIver s"$ignature 'Date
<br /> Load Information Facility Tire Program ID Site Suffix
<br /> f P(ck'Up Lj
<br /> Delivery
<br /> 0-no
<br /> � ❑-❑�
<br /> Facility Telephone Number
<br /> pm�; f `/ IJ ;� r" _ •'fir /
<br /> u ]Nboles7lrt#Count. Wa�ght in Lbs.
<br /> `VolUme,Cuh(c�Y�le'�WelgFrt 1n T'ons, 't f���.,s ,`"r`••J ;} I;
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<br /> — C•dtC ti{lrt4..l �C'f/1 s7�,�""t< s` i.
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<br /> �,, } ❑ Address8imn as hlaulv'r rnUfafb
<br /> IAir rCERTIFY THAT UNDER PENALTY OF PERJURY OF THE
<br /> fO , 'tAW!OF THE STATE OF CALIFORNIA 7NAT THE
<br /> F al UuNtl S10. � .gi ,.
<br /> INFORMATION PROVIDED ABOVE RUE AND CORRECT.
<br /> vva••t.aac vlVa 1476 ro as IV E_Vy al 1\.a
<br /> Com rNw t���� Y.,/•npA.rLpY,oapramen,o,..,,4ae,2–,zov
<br /> _ _ ehensive Tri .Nber
<br /> COIRCCyCIB E 'AMR L E . 11 2 3 t r .-. r. um
<br /> am«rdeiwonalNSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE
<br /> By.(ening Inls CA ComprehenaWa Tdp Log and R.eelpt,the signer(a)request that the Informellon provided on this form will be c ,%Idered con6denlial,pmprletary and trade aen 1.M accordance with TTIIe,14 CCR,Sectio
<br /> 17041 N e.q.,If-quest is mads fordladosure of this lalenoutgon.C.[A.,yol.wolf contact the Ign.,(.)of IN.term at the add,...and telephone number provld.d on thla form or recelpl.
<br /> Vehicle Information Number Nu
<br /> Truck DecHttrier•�lt(dY858
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<br /> Decal m
<br /> BtisinssTante• r,��,r�'!�',�` !1�'rw7 c��•rr�•Z' �/
<br /> 1/1 P1 — R0 ❑ ❑ Cif ass
<br /> City,Statc,and Zip
<br /> License Plate Number StateOlt-
<br /> I cerlflyrender penally d perjury unrhr the laws of the State of C.Morn4 Dui the Mormatlan pmvlded above Is 4w and cared.In addtl-.I am a.—0.1 lah%Ny -of IN.Inlam.Il n may resua In...pemlon,ra .lion,w denlal of ranw�al of
<br /> the Was le Tee I I.-IM
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<br /> n puuanl to Pubk Flats—Code section 42960 and may result M civil persA16s up to S 25,000 per day,par vidalbn��iriidsl N{penallles up Io$5,OD0 per violation per day as Oescnbed inpubao Hosourc
<br /> Cada sadion 42962 ,
<br /> -,T,--0-P co'.
<br /> Driver's Name(print) driver,' ; riature Date
<br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix
<br /> 4596096-- C Pick Up ❑ Delivery:•
<br /> Facility Telephone Number
<br /> Hauler Tire Program 1P / Site Suffix DATE " f
<br /> e w 0 Whole Tire Count Weight In Lbs.
<br /> :!`t r•— f Volume Cubic Yds.
<br /> Weight In Tons, f .Ltcft
<br /> ❑ 9 '
<br /> o hli;ui w(dam' t h
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<br /> lrr Tetephane NumberEEDD,H-Hw: � �
<br /> I��tciress Same as liauter araars
<br /> �__._
<br /> /r+' I CERTIFY THATUNOER PENALTY OF PERJURYOF THE t/�L
<br /> /L.� Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE. f
<br /> J' ! 7 INF()RMATION PRnVmFn AROVF IS TRUE AND CORRECT. '. f
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