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California lintegratediVilaste Managerrientao.ard <br /> � Comprehensive <br /> Log and Receipts Rot Bolt T259,Sacrarnento,CA,968 r2—UU <br /> A. <br /> Comprehens!ve Trip Number <br /> 7— I <br /> 2343 <br /> CiW,WB203('1�1'0'5)'I'NSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE <br /> 3 <br /> By signing this CA Comprehensive Trip Log and Receipt,the s!pn8r(S)request that the Information provided on this form will be considered confidential,proprietary and trade secret.In accordance with Title,14 CCR,Section <br /> 17041 et seq.,if a request is made for disclosure of this inform g tion,the CIWrAB will contact the signer(s)of this form at the address and telephone number provided on this form or receipt. <br /> 'Vehfddafion <br /> Hatiler Address <br /> Truck Decaf Number �e I r-& <br /> I - lRe. <br /> a cl�r <br /> 4-ddrc <br /> GS <br /> -U! , Sia4e aoid Z r) <br /> 'e <br /> y <br /> Ucense Pfafe.Nrum.bw ff Staie- <br /> MtON L <br /> CC)Z','-4 a C' 7' <br /> A <br /> I certify under penalty of perjury under the laws of the State of Cal fornia that the information provided above Is true and correct In addition,I am aware that falsification of thtsj�,fqrXa0oocazv;,resuIt in suspension,revocation,or denial of renewal of IhE <br /> Waste Tire Hauler Registration pursuant to Public Resources Cod section 42960 and may result in civil penalties up to$25.000 per day,PeLY91ja &K per violation per day as described In Public Resources <br /> Code section 42962 t-� <br /> C, <br /> Driver's Name Driver's Signature Date <br /> Comprehensive Trip Log Number Load Information Facility Tire PTogram ID Site Suf Fix. <br /> . - 1 1, 1 r--7 r-7 r--1 <br /> ❑ <br /> 3234307 C Pick UP [],befivery ❑ ❑—❑ <br /> u Li Ll <br /> Facility Telephone Number <br /> UY F1 <br /> I Hauler Tire Program ID I Site S iffix DATE <br /> ❑❑ `T ❑ <br /> W. Whole Tire Count Weight in:Lbs. <br /> �Da. <br /> .2: <br /> Volume Cubic Yds.❑Weight in Tons <br /> E <br /> 0 H�Lulla'- KZ7,qs� <br /> F- <br /> A6&ess SaiTte?,S <br /> (N IA r <br /> I CERTIFY THAT UNDER PENALTY,OF PERJURY OF THE <br /> Who, tire.) LAws or THE STATE OF CALIFORNIA TH <br /> ATTME <br /> Whole <br /> INFORMATION PROVIDED ABOVE IS TRUE.AND CORRECT. <br /> !`rAx-qivL-Trin 1-46 Number Load Information Facility Tire PTograrn ID Site Suffix <br /> ick Up. Delivery <br /> —2- 3234307 B <br /> 16" Pick IRE 5E H RE-27 <br /> 0 Facility Telephone Number <br /> WO Hauler Tire Program ID I Site affix DATE <br /> La�®`Whole Count Weight in Lbs. <br /> EI <br /> ffix tDA DATE 17 <br /> LL'N <br /> I W <br /> r <br /> Vol <br /> I Z-1 1 1611 Weight.in Tons, <br /> lume Cubic Yds. <br /> E W ar" <br /> 0 Hatuier <br /> L) OJ <br /> S le r <br /> Initials <br /> e 'n C�ri ra r <br /> ,(N IA for t CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE ARDCD�RECT- <br /> - - - - - - L a I fo mation Site Suffix <br /> Comprehensive Trip Lo4 Number o d n r Facility Tire Prograrn ID <br /> 17-11 <br /> e 1—A 34307' m <br /> L <br /> P" MAAAA! <br /> Facility Telephione-Number <br /> Hauler Tire Program ID I SiteSuffix <br /> 'moi. �' t��4r��tiny 5"t... '`�:��,7 - Er'+rr3'��'fii. ra.' �' I. !� az+r 4 1'.F 11❑ C�1 'L� � �.1I. <br /> NOR <br /> V1 <br /> I <br /> as , <br /> -ip r 7 <br /> ^ fzrffafs <br /> A0CF-nrtFy-THA.- Ov PEI Juw.y O.jl� <br /> STATE OF CA'. F-TfIA 1 11AX-.H_ <br /> THE <br /> ROV[LC-Z AIAO:-=IS TRUE AND 0ORRECT. <br />