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Toll Free 1-866.896.06001 www.clwmb.ca.gov/Tires/ <br /> California Integrated Waste Management t3o•rd <br /> CA Comprehensive Tri Log and Receipts 10602 P.o.eox12s9,$Rcr•m•ruo,CA95912-1169 <br /> x A M P ! 2 y_ Com rehensive Tri Number <br /> - <br /> I La <br /> c rem(mv INSTRUCTIONS ON BACK OF PART 2 AO NOT TAPE,STAPLE OR DUPLICATr= <br /> Ey$,King In f enc,-p.t�.n,Tr4 *M�o9+ Rsb*4,uta*i9ftels)vestwoe rW as rnroem tion p-lded an this lorry will be e.nslaired eonrao <br /> a„.l,propr4lsry and bode caenl In umdanca W11h Tltb,to CCR,ficDon <br /> aTMa ••q,lf■rwvastlsnmdafordtsclosarsofthlslnlorrnatimtheCWM6rr111conlutlhsef•n•r{sjatft form N(he■Nrin9-dlslaphonsnvmber rowldedonthisformorraaipc <br /> Hauler Address � <br /> Business Name �f>�r '`'�f�ti �'Y'f. <br /> Addess <br /> tyrCState and zip <br /> 1 1C i ❑ Common <br /> Carrier <br /> Ioa�yv pvlattYolpOrjuMund•rMMwraNaS-Is atcarvantlathat Eptoonodonpro,l0sd&bows{sWaand coaMModd&n,lamWorsmat A donor Mromumnm■�ssyyreaminwspenaan raroo.twn,waadalarmetrud <br /> Waeta Tia Mevbr Rsaktadm pursuant to Pubic ftsavurus Cuda seeion 12p60 and mey rcnat h dr l penabfea w a Z 25 000 per ddY per:;,,n , 9 *4 up to A000 per 4019on par day es daswftd In F bVa Rss&deu <br /> Code sedlan 12!02 <br /> •�� (�{ _ laic i s��-�,.� � .�,�C..,_. � � l .. <br /> Driver's` ame(print) f.1 very rtetule Dat 66 <br /> a s <br /> 3248895 w- a o o a o 0 o-a a <br /> Hauler Tire Program ID 1 Site Suffix I i Facility Telephone Number <br /> 0PP-noa000a <br /> o 10 hi. 11161 1 — FNr'nai tn;ilfaitlyAI ,t�G y'I <br /> I)1 Mauler NaTe e <br /> fG <br /> .. ( �'t�d•4�1� <br /> 2 <br /> Hauler Telephone Number ❑ d� asatllel�'i' f„l� s <br /> CERTIFY YrIAY UHOEA PENALTY OF PERJl1AY OF THE <br /> utwS OF YnC&YATe of CALIFaatnw THAT rHE f) <br /> UrlOtAlAY]ONPAOV]aEDA90VEIST$tUgjkNOCORREOr. I •1 <br /> • a. a s s • <br /> 3248895 " g ED 0 <br /> Hauler Tire Program ID 1 Site Suffix —Jr Telephone Number <br /> H H H—Ba <br /> ;^ar•Ility uSi Ass <br /> 110 0 -211161 ( M11110 r . <br /> Hauler Name Ci y, air{ <br /> i 7. GCS I c., r <br /> /, ref yv 1 i '� 1 5 and Or Label(A <br /> , <br /> Hauler Telephone Numbej { ' ❑ dFs$3arile aiiv( u1or 1�j.)n7}�: J <br /> • I CEAriFY YHAT tWOFR PENALTY OF PERJURY OF THE <br /> LAWS Of THE ATATE Of CAt1FOUTA THAT THE ,�!'j✓� <br /> l r H N PROMOED ABOVE ISTRUE AND CORRECT. <br /> • - • f ■ <br /> go n113THIMs <br /> 324.8895 M11111 A i LJ ly1 © ❑ D ©-� ❑ <br /> Hauler Tire Program ID 1 Site Suffix Facility Telephone Number <br /> oaa aoa � a � � <br /> ( <br /> I�I.11t1wAJlll,l'�� <br /> 'Hauler NamePA <br /> t�liY�}�•s ItIrJ a.iw <br /> C,(- V �iallll�.s tri r S <br /> H�„I.,T.1—h— Al„r f— 1 J 171 Arldracs: A ;rf�af6T4zeeris.rr 1_ ...':I r i�J <br />