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AIRBC►CIBE X A M P 1 2 3 4om renenstue 1110 Number <br /> .reel6aerw. '5 7 5 7 6 , <br /> oeure�rde:al�nwINSTRUCTIONS ON BACK OF PART p0 NOT TAPE.STAPLE OR DUPLICATE <br /> By elgnlno this OA Comprehensive TAP LOU and Roo olpl,the signor($)request Iha(IM Information provitt on tills fort wilt bo oonei,, d oorf(Id•n11d,.propdalary•nal Indo soomL In aaaordanae vdth Title,14 OOR,Spogon <br /> 17041 et seq.,if o request le made for dleoloetoa of this Information,Oalnooyolo will oonleol the signer(1)of llib formai the address and lalepbooe number providodon 1106 form or r000ipl. <br /> til�ei seat NUmbar Hauler Address ec D, <br /> Bgslne6s Name <br /> C y Q AddressRetf 11 r7 `)7�►G�x'Q OP <br /> 'a City,State and Zip <br /> dans. W ate Num �r state; 'c'�r1r're'GD <br /> DIM Calder <br /> I hlfy under penally of perjury under me latus of IM stale of California that the Information provided oboyo is true and eprram.la addition,I am aWam that Wallicellon of this Information may resuilln auepo.Won,revoeegon,ordlotai olroneWel of <br /> the a loci Tire20Wer Registration pureuanFb Public Rosoureoe Codeecetlan 42860 and may result to olvu penalties up!0526,000 par day,per Nolatlon or odminlitrallvo penalties up to$5.060 Per vlolafUQA described InP Mgt;Rosouraes <br /> Cddg ee a Tka 2602 <br /> Driver.'s Name(print) Drivers i nature Da et <br /> 'LA <br /> Comprehensive Trip Log Number <br /> Lo' <br /> r e 6Facilify <br /> Program <br /> 11 <br /> F,r Ttr. <br /> IT <br /> 7 5 7 6 8 no Am .� €1 Pick Up <br /> Hauler Tire Program ID / Site Suffix'g ss ln �:' ' ` i ! •Facility Telephone Number <br /> p ODD�aaaQ000 <br /> ❑ Whole'�Ire Gour:E �_Wei,ghtll)•C;b"s,��� <br /> hi)rait Y 111 <:iPie c: <br /> I I Islam Q Vc4unio,00hic Ycl', El Weight in Tons f4mmi'Additsss <br /> ` Idauler <br /> Name Oft"Statu ei)ICI Z ip <br /> Ut i titzu?ip r))•Lrlbul 0K <br /> Hauler Telophone Number . _ Address Sante gas Fibular nlHals —1 <br /> 1�/Afar IC6RTIFYTHATUNDER MALTY OFPERJURY OFTHE <br /> I y+ ,WtI4I0 Tiros) LAWS OF THE STATE OFCALIFORNIATHAT THE <br /> i rl i\,--:- .•r gIFORMATICN PROVIDEDAEOVE I6 TRUEAND CORRECT. <br /> CoMprelfenWitbi <br /> rilp.- 1a a• 1 1 1 • • <br /> 4 r <br /> v. ' it <br /> Y <br /> -757689 __ B n 11 r41Y ' �` IEaj)11�1"y 1 ® ✓ ) ate` <br /> u.: Faaili Tele hone Nu bar <br /> I a Hauler The Program ID / Site Suffix DATE ' Q t,`.` ,. .� lnnj ty. p t1. <br /> Lu .Whale TICe Count WeIght In LGs. <br /> � . P—M o fl o <br /> y 61 0171 r.., 161 F1.Volume.0ublc,Ycle, WoiyhtlnTons' itAfir �, �pti¢-��/ � (/ <br /> Hauler Name GM.aa LT la A�ezj�-77 ie / <br /> Hauler Telephone Number7. ■ U Address 5flmo al)Hauler InflIvis <br /> (NIA(oY- 10ER71FYTHATUNDERPENALTYOFPERJURYOFTHE <br /> �NIiO�k�7�eel + LAWS OF THE STATE OF.CALIFORNIA THAT THE <br /> ORMATIONAROVIDEO ROVE Is TRUE AND COAR60T. <br /> Comprehensive Trip Log Number Load Information Facility Tire Pro rain ID Site Suff ix <br /> 5 7 7 lJ V � W <br /> TP. ` <br /> kiB�tleYTire Program IU / site'Suff(x 1 liao[IityTelepltohe,Nuhnber ` <br /> .., I I <br /> i���J_1JIIIRH <br /> ... c,") f � B�� ���,� �•� '3t nt' f 7fv�//>,dEtr�'Fas / ,! <br /> s <br /> Hauler ialepholio NtjttllipY ;:.'.,' I I ' 'Add)es SQtre H .'};(aul,�Tr <br /> t ls. <br /> "I'ERTIF.Y.7 AY.dNO )RENALf..YW.IIRJURY.i7r, 11 <br /> �W T�V.yR-�,4 G1 t+-�•— res, x L p f•AWsOFTHESTATEOFCALIFORNIA THATTHE <br /> `Y tJ 4Y I A ir'•,.,, - :-INFORMATION PROVIDED ABOVE 16 TRUE AND CO RR6CT, <br />