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e California Integrated Waste Management Board CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 �'-'I_--�e'e. E x Apnn P L EI i 2 3 Comprehensive Tri Number sd.a« ; 3248304 aHlife2g�(toiosl INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE By signing this CA Comprehensive Trip Log and Receipt•the signers;request that the Infom+ation provided on this form will be considered confidential,proprietary and trade secret.In accordance with Title,14 CCR,Section 17041 at eoq..If a request Is made for disclosure of this Information,the Cli will contact the signer(s)of this form at the address and telephone number provided on this form or receipt V',ehicle In.formation Truck Decal© Number Hauler Address �r07-.J4�a © ® a a Business Name Address G 13 p k L/a License Plate Number State City, State and Zip L PHEE © � ©� Carrie rn I certify under penalty of perjury under the laws of the State of California that the information provided above is true and correct In addition,I em aware that falsification of this information may result in suspension,revocation,or denial of renewal of.th Waste Tire Hauler Registration pursuant to Pudic Resources Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or a "isbative penalties up to$5,000 per violation per day as described in Public Resources Code section 42962 �� L�1�.STM� ✓J9�1 �07E �A4 yUf If Driver's Name(print) r+B - - ignature __ Date 1 Comprehensive Trip . • .. . Information .. • 3 2 4 3 0 4 C Pick Up DeliveryIONNNHEE HOT . Haulei Tire Program ID• l Site Suffix DATE / / 0 p Facility Telephone Number :4 Weight ht In Lbs. 09 Whole Tire Count 11g FFacil't fFt� v y D ItJ V /^ (/ ❑ Volume Cubic Yds.E]Weight in Tons Na e Cit, tate and Z1'p E Hauler N e Stamp or,Label OK a Hauler Telephone Number ■ Address Same as Hauler, rDrrrai: /y�^ �r•1/' (N/A . I CERTIFY THAT UNDER PENALTY NI PERJURY E THE 7 WhOIB TiMS) LAWS OF THE STATE OF CALIFORNIA THAT THE 7 INFORMATION PROVIDED ABOVE 19 TRUE AND CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix EL 3248304 -- 8 Pick Up aDeiivery © ® aaa -aD Hauler Tire Program ID / Site Suffix DATE t5 Q Facility Telephone Number �o oa : oo Ail- Lu Whole Weight in Lbs. Lu ® hoe Tire Count g 1 Fa lilt Business d 3 3 .' Volume Cubic Yds.a Weight in Tons N �d � a / • �� o Hauler Name . CitjQ.�opg)/d��7{ U) am 4 OK. Hader Number• EOOE�MMHN Q •Address Same as Hauler initials'— (N nruars; (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE -(5 Z whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE (r INFORMATION PROVIDED ABOVE IS TRUE ANO CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix .3 2 4 8 3 0 4 ,-ti A • t Pick Up a Delivery Hauler Tire Program ID I Site Suffix Facility Telephone Number y r DATE HE / HE / Flu A w ®Whole Tire Count El Weight in Lbs. a' Facilit EC9U 3 3 / 0 Volume Cublc.Yds. Weight In Tons o .Hauler Name In r Starrr�p r L .,41 1( Hauler Telephone Number Q ■ Address Same as Hauler Initials •n/ //J •-/ /"• (N iA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE s�� •� QO • —/ Whole Tlfes) LAWS OF THE STATE OF CALIFORNIA THAT THE O y(/ `'tel• INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.