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<br /> mpreheh ,.. .-el :...Log and .'.
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<br /> 1 i!1 \i0 1 "`• .- -:;�e';sb��tesUG�6e's?Ij b�q(,rj�;eittl•keoavary
<br /> SIV'@ p 'BCt 'I� S 1,0.06i* .w fao;abii125B;5EdrAhiento;CABd812-1268
<br /> �CReivGfe E X• A M P L E 2" 3 Com rehensi a Tri 'Number
<br /> afekralrtt+7%)INSTRUCTIQNS ON BACK OF PART 2 DO NOT TAPE S A LE OR DUPLICATE 4'.Sir fr4Ft yyn', : Yl °IS;.`:r.'a�xf>' ,,;;.=
<br /> By dpninB[1113 CA 0011,pr4hendvl Tdp Lap end Aecelpt,the d2nar(e)nqu•d that the Informellon provld•d on thb form will h•conddend oonitdenllal,proprlolery end treda Dont.In eovonienoe WIIff71110;14 009,Section
<br /> 17041 at seq.,If a raqu4el Is meds foi,dllpld(ynor I".InlomiilIdn,CeiRooyolo will cantaol rhe sl8ner(e)of Ihie farm sr rh.add(eee and telephone number provltlstl on rhp fo,m or naolph
<br /> 't. r ?b": n: s.,°s�iL�i. .•.�'!+;�1:�). �SCa�_�.v"�Ivlr�i.
<br /> s : ;• w;' Business Name
<br /> ;�• a ' " ,' Address Cost Boy Tire Compony
<br /> City,State and dip e 00 �-- untinc yq
<br /> � Ian Dr
<br /> M
<br /> �
<br /> Carrier L Fa i i`i"('�;pir'':r C3 r 94-:533 3
<br /> loerrlry under peneltyolperJury tmderlhe lave of the Slel.of C•Ilforn4lhal the lnlarmel nproNded above le true and oonecl.Ineddlllon,lem era Thar falsification of lhte lnforma6on may result In awpenslan,revocation,or da}tl•I or femwel of
<br /> the Waste Tlfe Heul•r Ra9hbalbn pureuenl to PubBo Coda�eclion-02880 a me In olvtl penelUes up to$2ti,000 per day, W etlon ar edminletrat a pene""s up to$6,000 per Vlolelbn pat day as des phed In Publra Resources
<br /> Oada season 42802
<br /> Driver's Marttg(kr-Ih Driver's S19r urs ,.,. Date
<br /> Comprehensive . • .n Facility Tire Program ID
<br /> Site Suffix
<br /> 5630768
<br /> 0 ®EU.
<br /> Hauler Tire Program ID "flj phone Number
<br /> I g /' sit Sufflx "TJE . r r Facility Tele
<br /> M.
<br /> iY'ole fI,Y !G6unt WeighEi 00
<br /> F ` r. ,4 1 VCtItiiYrl3 Cublc:Yds,
<br /> 1✓`lrility BU lurt)es�$�
<br /> : V . )' �• Wow. tilr Totts Name/,lwtiross I Harris nvenue
<br /> s Hauler Name s:' ! :,,: 04y,Stctte erRikirL'1mento GH 95838
<br /> Elbel CW
<br /> _J
<br /> Hauler Telephone Number
<br /> i Address Same as Hauler lnwals
<br /> (N/A for IOERRFY THAT UNDER PENALTY OF PERJURY OF THE .�
<br /> GFf WHCIe 71Yee). LAWS OF THE STATE OF C712qALIFORNI0.THAT THE
<br /> INFORMATION PROVIbEO ABOVE IS TRUE ANO CORRECT.
<br /> Comprehensive1 LogLoad Information Facility Tire
<br /> Program ]1 Site Suffix
<br /> Ep 'ED :U
<br /> Hauler Tire:Pro_gram ID / Site Suffix : aepityelephorie Number
<br /> . .,.• _�:_ ,..?f• 55'E�E •rf:Bffli�%!: err °`.��%�•-_
<br /> Lz
<br /> 's.,e - � .. , t .I.; ;' '`('�3 11l'•1ST}�j�%yllrL.:r ' - ,`
<br /> I•{auler Name �^ ,a` " ' �"�'���. a(t�•,tj�s���r-�;'�•-� C.'�'�+
<br /> j is�I '� ± 4 Z.
<br /> .:::: r, 'aSDltti�S ) f 2-S, ~
<br /> Hauler Telephone Number' ;F I 1`''' �`� Address-Same as.ka-0ee --'
<br /> I CSRTIFYTHAT UNDERIPENALTY OF PERJURY OF THE
<br /> OFT!{E STATE OF CAUF,ORNIATHAT THE
<br /> N•PIrbVItSLO ABOVE ISTRUE qN"COR.ECT.
<br /> HeComprehensive Trip Log Numbere • InformationProgram
<br /> r r Site
<br /> Suffix m
<br /> 5:630766 A ,' - y,.� `I�, � 1 Mg
<br /> , A17-7-1
<br /> Hauler'Ttre Progrgm:ID % Site Suffix :acilit i-sle0IJ06 7ryuri ber
<br /> ,'• // '
<br /> 7s (•'I• r
<br /> 000,..-D iooa
<br /> • ;ya( •}� ,.',�x''t;,'- 1`. j:• y�� J—'- 1�tllla;:l,:.5,1
<br /> Pr
<br /> 1 Hauler ems' .. . . ;$.�. � ": .'a' -i?L1 , a •, t::I` 'i.• :Ni3 ';•1' 1 `,� :1 :a•
<br /> I,iA13F;1'"rh; - _.`+,-"•,
<br /> Hauler Tele Naito ', i .J43 I,.r j
<br /> ipp4 Nurxrber L�a � f? �u1fc
<br /> T x 1'� s• 7� llliels
<br /> ' .Y�y. ,. I' ,1P _(4.7�_•'r 1.§a, 'r (CERTIFY THAT UFIDEftpfiNALTYO RTOFTHE
<br /> LAWSbl`THE STATE OF CALIFORNIATHA7THE i.,,.Y j•
<br /> 'i" r' -r'.'t V' T"~ �IF r1Jl�..•:h13 hY�I/.'t.111>A-ry-+k c'Gll' Jc'ZLr>..5: 'i' •i
<br /> INFORMATION-PROVIDED ABOVE IS TRUE AND CORRECT,
<br />
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