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-- � � �� c_r� °��� dog and Receipts <br /> _ VIo:O Boxm259Sacramaento;CIA9'56`T2—T2591 <br /> ... .3'i P and 6V,rS• <br /> ....a <br /> (Rdl't !fie:.en5iveB'F Number <br /> -. E STAPLE ® ��rC�T=1 <br /> 19186490 <br /> 5ia.o-ofCaAlcmra INSTRUCTIONS ON In <br /> PART 2 D"® NOT TA.P <br /> :IWMa 203(04105) <br /> By signingahis CA Comprehensive Trip Log and Receiptuest that the information provided on this form will be consideredconfidential,proprietary and trade secret In accordance with Titre,14 CCR,See' <br /> 1704?et seq.,If a request is made for disclosure of this itWfv1B will contact the signer(s)•of this form at the address and,telephone number provided on this form or receipt. <br /> Tmlckc Decal.Mv;nbeifl. Bims!i <br /> RO <br /> 27 <br /> t:iceskse Pjatet a-ober r 4� ,,..�5.LJI 2E ^..Sly,. J's, °Q:dory t �f: <br /> at <br /> On of this <br /> on may <br /> I certify Waste TiredHau Hauler;ty of Registration on puL(helaws <br /> ResouarcesfCode se'Ion 42960 at the nd may resultmation din civil penalted above Is ies up to$25,000 pemect.in rue and codr dlaly.nperaviolat violation om aware r administrative i 'ln�penalties up to$5 000 per violation <br /> el ontin ppe suspension,day <br /> as descldbed In Public Resourcon,ordenial of renewalesf the <br /> Code section 42962 t /'�✓"' �� �`/ '� <br /> Driver's Maine (printf <br /> Dr :er's Signature _ <br /> 3466490DefiVerYUP- 7 FI-11 01Pick <br /> Facility Telephone Numberry t <br /> hauler Tire Program BD f site Su ix DATE lr <br /> ar. <br /> . ... <br /> 0—DrU <br /> "= Wholehole Tire Count Weigh <br /> ut t in Lbs. <br /> @: �" acwt Business <br /> 'Vafurne Cubic Yds. Weight in Tans iyarn 'Arid ess <br /> %ty,.,;tate and Zits <br /> Number 0 Hauler Telephone Nume <br /> � � 5-sarrj;r or Label OK l <br /> initials —� <br /> S91e-Tires Only 0- <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> . for Whole Tire Count. INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> ! 1 <br /> t <br /> *aMal! <br /> Pick'U. Delivery f. ` Ld. <br /> � $64.90 .� p: <br /> ;. ., <br /> FacilityTe1hcrtie Number <br /> F6auler Tire ProgramkD f >ite Su � DATE ,� / � J <br /> ` rl r f <br /> Y t <br /> dj ;D,N, Ie Tire Count • �Weiglif rn Lig _ . _ <br /> c' a: i�Facilit}f czEsirEess <br /> _ Volume Cubic Yds a Weight m Tans Narnel�ac� eess <br /> Ceti,State and Zip <br /> o:: <br /> y fouler� Telephone Number � ;� Ir sta tap as Label OK <br /> "j andtials i <br /> f CER711Fti THAT if5,'DER?.'`'AL iY C+=pEFL"W..Y DF <br /> L' Whole Tiresonly [. ! iAVJS OF'i EHE STATE OF CAL1FOP-74tATf`AT SHE <br /> .fQr';W hole Tire C.oEIR'Y�• ENFbRhf4 'Sh`PROVIDED A9OVF 7S.TRj E AfM CORRECT. <br /> ! 1 J <br /> Fr�i< l1p <br /> 3086490 <br /> D�eliv�ty <br /> ar wo '� I <br /> mFacility Telephone Number <br /> �,. E <br /> Hauler Tire Program ID Site Si: tcx D:ATE. . <br /> ;. <br /> 4VEi6le Tire Gaunt iliFeig,ETf fru Lbs <br /> asaC;l'St�f Business <br /> g E} VoEuine•CetbEcYds �yt�ePgbt ER ToCTs larria/Address 7 <br /> Cil:,y.Stam and Zip 't <br /> E ' <br /> Hauler Telephone Number � r- � 1 � Stamp LEbei K <br /> An <br /> J �i or lM be €3' <br /> (.� a,.,, '✓7 lw ! Q L.. sem' t� +Srtl:;a!cnunmrmaw,. <br /> - i Cu—,r.';'TflAF Ji D FF"i'i'.'tY?•-R3'1RY^i T E <br /> (i14t <br /> Whole Tires Only. LAWS OFT HE. <br /> S A7 LfFORNLiTHf,T^s <br /> for Whole Tire Countt�Orf...TIDN FPOV1')-D A=_<1V'IS TRJE AND COPi S <br /> I-�ean_ea':Tact:err.ss�c�esa�',:�tomvs"rz�rafla.�aQrr"es:+- - . <br />