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California Integrated Waste Management Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95612-1259 <br /> ...... R` X A Jlu► <br /> Comprehensive Tri Number <br /> •::: _ <br /> Slafa u/Calllonaa <br /> clwnlez9a(foioe)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATEE 3090315 <br /> By signing fill.CA Comp ehensive Trip Log and Receipt,the signer(s)requost Ihal the Information provided on this form will be considered confidential,proprietary <br /> 17041 at seq.,If a request Is made for disclosure of thisI donna tlon the CIWMR will contact the signer(s)of this form at the address and telephone nuniherr r y and bade ii or re ei accordance with Title,14 CCR,Section <br /> - P provided on This loran or receipt. <br /> Vehicle._Information <br /> _ _ Hauler Add <br /> Truck Decal Number Address <br /> ISusiness Name f !._A,_ - - <br /> f 4 1,� 8 co t`-A � <br /> (':ity, State and Zip <br /> License Plate Number State # <br /> a U ao aP <br /> a , �:I,f f��I 1 r l f 1 � <br /> I cel Iify a),far penally of J o Jwy w idol 11',laws.4 It'.Stale ul Ca6lomia(hal the inlunnaeid <br /> on proved above Is true and-liuc(.In addition,I am aware that falsification of this infounallon may rosull is suspenslon,revocation,or denial of renowal of Ihu <br /> Waste Tire Hauler Regislralj n ph,­,,t t to Public Resources Coda seclinn 42960 and may result In civil penalties UP to$25,000 por day' UI,Par VIUIa11U11 adlilll llsbalw p nelties UP W$5,ou)per violation per,day as described m Public Ro <br /> Code sect n 42962 ii1. <br /> .y <br /> k �=�—� � �t��l�r�=.�...5.��`� �9�.. � �„�::s.r�,� i i t r ..�r l ��� _y�•_ _.a 1� _ ; <br /> Driver's Name(print) Driver's Signature Date <br /> Comprehensive Trip Log Number Load Information. ProgramSite Suffix <br /> Facility Tire <br /> «p <br /> a 3 0 -- C ❑ Pick Up ❑ Delivery <br /> U <br /> m Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> ¢ g DATE a� y p <br /> w CL Whole a a <br /> The Count Weight In Lbs. <br /> m ~ Volume Cubic Yds.❑Weight in Tons a <br /> E <br /> 0 <br /> U a i <br /> ■ Initials <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFOfIMATION PRO VIUED ABOVE IS 1'R 11E AND <br /> mom";; <br /> • • • • • NumberLoad Information Facility Tire Progrq'm.ID Site Suffix <br /> 3690315 " B j Pick Up ❑ DeliveryIT <br /> 0 � 0 <br /> U <br /> °' Hauler Tire Program ID / Site SuffirATE0 <br /> Facility <br /> Telephone Number <br /> m g pc: <br /> NCoMprehen <br /> e Count �Weight in Lbs.ubic Yds.❑Weight in Tons0 <br /> 1 <br /> ■ Initials <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> INFORMATION PROVIDED ADOVE IS TRUE AND CORflECI'. <br /> a "� ��; � " 'Z -- A Pick Up Delivery —LJ <br /> Hauler Tire Program ID / Site Suffix DATE % t Facility Telephone Number j <br /> oa oa oa OPT nOF1 <br /> m w Whole Tire CountWei ht u <br /> a g In Lbs. <br /> � ) � ' ,t •r �r qi r I � � it <br /> ! F Volume Cubic Yds. Weight in Tons �•k-•I � , ���e '�)r l { f / ` <br /> o <br /> 1 <br /> ■ <br /> initials 'I <br />