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u. mu,u v m o vs•sm•. arms seer qY•y q N„R VO'0 n•Y�66(i C a.a11rsg,w.%.TR.PWY L 6Q TY OF6 �er�eattavoesswm�w - -�• -_ CA � � a � affwS., �� California:l''ntegrated{Uaste Management Board, and R.0%Roo T2:59%Sacramento,Ca95872-1259I 4- f - Dom relaerusive Tritdmbe 3234308 CIWMB 203(10105)INSTRUCTIONS:ON BAC OF PART 2 DO NOT I-APE,STAPLE DR DUP- ICA.TE,i By signing this CA Comprehensive Trip Log.and'Receipt,the st ner(s)request that the information provided on this form will be considered confidential,proprietary and trade secret.In accordance with Title,14'CCR,Section 041 17et seq.,If a request is made for disclosure of this Inform tion,the CIWMB will contact the signer(s)of this form at the address and telephone number provided on this form or receipt. i[YfaLtfl¢K4 � `.. X:-- Lkaeryse. �044"541Trackaecab fVum6:er ��ttfiel'��reSS ' /' LJ. l J �� ?' � � .��'•i•�'{.lit f:' .:� (({{�/�/V,Mate Nmxher: Sta:ee �F. r r I certify under penalty of perjury under the laws of the Slate of Calif mla that the information provided above is true and correct.In addition,I am aware that falsification of this Information may result in suspension,revocation,or denial of renewal of th ' Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to$25,000 per day,per violation Or administrative penalties up to$5 00 per violation per day as described in Public Resources Code section 42962 I Driver's Mame(print) Driver's Signature ate Comprehensive Trip •• Number Load Information Facility Tire Program ID Site Suffix 3 2 3 4 308 IIIIIIIIIIIIIIf C Pick Up Del iveryCIL U — Hauler Tare Program [D 6 SiteSuix Facility Telephone Number y DATE a El Tire Count Weight In Lbs. El G.- (D I I tea.. Volume Cubic Yds. Weight in Tons E El fn. U socf _ 4 A�i!i"4G.i0 [F.;2:it( � a i''eSS-c`'ess scarne a's-Ha S s Initials ---- (N 1A.for t CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires, LAWS OF THE STATE OF CALIFORNIA THAT THE IN PROVIDED ABOVE.IS TRUE.AND CORRECT. • e • Loj Number Load • • Program 323430 $ B Pick up.2- 0 [Rb,. ry H E E R � J & Hauler Tire Program ID ( Site Su ix W[� Facitity Telephone Number DATE . / HIJ R Lu Wh Ie Tire Count ❑Weight m Lbs t'y r 7 I a.� ( ~ Voiumd Cubic Yds.®Weight in Tons 0 t i dl.ler L) Sr r V " i' � V e sDOD i ' l ;:-e=S,S nne as F'ia,fl ' initials \ (KfA for I'CERTIFY THAT UNDER PENALTY OF PERJURY OF THE CWhole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE VVV INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. �uComprehensive Trip Lo� Number Load Information Facility Tire Program ID Site Suffix. ' Hastier Tire Program pi] B Site Safi xB 0 0 FaicilityTelepIliCln Number I tv; 1 ��aeTr'.e�.,arte.xara•.�.yx.{µ,n a� -r}a �zsrn+' + I 1 I 1: , bl, '^1i.'JlhT �"F,`j•. r a^{ T-�J f- ? �y y+^'ti •.. a •"v - fJ r 1+ y� r.�.,'• } 't t1 �_ `I ieI ,�rl •_7'� '1' i'I ii' i � h�i� � Qle 1{��,i �.Y. I � �..ld)Its4i. .^ .. «� ' •1. = L.(�i,ilG'�'(V i.i�tl'� jl�i�.f''S''. ah_i�'t y'a1.'TS:�-a.'�C rI�-7•.•,r#ry��'� +3:. �i. t _ .. _. _ r t S• I rr':C, e. z u Fnittats ... r C--RT.--Y THA'.UNDER PENALTY OF PERJURY OF THE / 4 i, t• •` i ` 1. '� 1 - - t &�.l.f.�`"Il��J. LAWS' T:9E STATEG OF CA� ORNIA THAT.THE •Y'^w•( fes' "~' Y t't:v1 I - y VVkfefe TTrest [µFO'., T!1 PROVIDED ABOVE IS TRUE AND CORRECT.