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b= � :?i ,hif f P. _ :-Z I 2 F .�:..- 1 ,. .rl a.o+�ue et ealso e Trip^ Is to bier <br /> 1 Slate-c.•wllfornia , I 323-1594,: <br /> 3"i 1 5{,� <br /> ciwmB2o3.(foio5J INSTRUCT[€�NS OFA SA K OE, AT2 Q NOT, TAPE STAPLE OR DUPLi�-,JE ` K-JY <br /> By signing this CA Comprehensive Trip Log:and:Receipt,the Igner(s)request that the information provided.on.th is form will be considered confidential,proprietary,and.trade secret. In accordance with Title,14 CCR-,Section <br /> 17041'et seq.,If a request Ismade lordisclosure of this Inform tion,the CIWMB will confact the signers)of this form at'the address and telephone number provided on this form or receipt. <br /> .: . .� <br /> :r <br /> Truck Decal I�lurnher F � <br /> Lrcerrse:rPlate FtFiember. State 4•'l;! :z= •i{t9 t:;�9 l� E-1-- <br /> �� N 1 � ., r :� �. <br /> I certify under penalty of perjuprunder the laws of the State of Cali omia thatthe informalion provided above is We and correct In addition,I am aware that falsification of this inlorm8fion ma result In suspenslon,revocation,or dental of renewal of the <br /> Waste Tire Hauler Registration pursuant to Public Resources Cod section 42960 end may result In civil penalties up to$25,000 per day,per violation or administrative penalties up[o b6, �� I p&gsyas rlelCllDeYl(gf+ybfprces <br /> Code <br /> essection <br /> J�42962— �� •k, i - i L+pe�lj <br /> Driver's Name(print) /— r'b0 s SignatureDate <br /> Comprehensives Lop Num-bgr Load Information <br /> Facility Tire Program ID <br /> 3231594 E� ' pick Up De{ivey110 0 <br /> - <br /> -u - <br /> Hauler Tire Program ID f Site S ix <br /> Facility Telephone Number <br /> D',.. E' s t I/ <br /> Q Whole Tire CountU Weaght to Lbs. f�. <br /> 0 Volune.Cubic Yds. Weight in.Tons <br /> c <br /> ;..e.�a�,or�"PyP..ni"i✓.3+G r�;ii 3l';. R. I r.u,".."ti:_ �.....t. _.�5 F �„_5'.-:. Initials <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY DF THE <br /> VMoIe Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip Lo6 Nurriter Load Information Facility Tire Program ID Site Suffix <br /> y <br /> 3231594 --]Su, <br /> Ll Pick Up 2 Delivery 2E61H U y u <br /> 0. Hauler Tire Program iD f Facility Telephone Number <br /> DATE <br /> Lu 99olePTif <br /> � Whole;Tire Count �Weight m Lbs. � � <br /> ` 7 q H 1 I � fumeCubieNds. Weight in Tons45 <br /> F- ■. t t .C.� c:ii° ? I'icr;;.'' Initials <br /> df�i'<u�:'r <br /> O/' _ I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> s Whole Tires) LAWS OFTHE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> 7. <br /> Comprehensive : lin Lop Number. <br /> Load I litdr ',o.. `I g, ill <br /> -Site tknx <br /> ' c re �p i ,4yy��•,y�y��; Fr`lpr�rpll[r� itFy��[F�[': <br /> r <br /> 3231594 �.� rr � �� S�li r r .b r IJ — <br /> '�•"z ' � � `� - FacElity Telephone Number <br /> Hauler Tire P"ragram D f Site Sec u �� �'�} r y z 1" 17 <br /> 4. <br /> 1 - u'�r .n.R� L - i`v Imo_ � r k _ c •� y °C 1 <br /> ul a r N a,!r,e' i "°'�j,�t±��•�i.�r,d.'3. t�. x �.. �-u�..r' - .. 4 s-. k <br /> r Me <br /> I.'�"'E, C.-rr �!fi Z f�'c..i r � i L r �• .� --� ~ I i <br /> Initials <br /> r s„r T%%ee•~ e P tom? c a <br /> ' .7`ay GER7(FY Tf4A,T UNDERFEFL�CTY OF PEfftlffr'.Y 6F THEyLy _ P <br /> a-3 x <br /> f 7 y LAWS OF THE STATE OF CAYlF04RT+4.12C1uT LHE <br /> ••7 ”•• :i + '-. .. ,-, ,--_..... „ k -f"..r+ s�F INFORMATION PROVIDED ABOVE IFTRi IE.'.,VD GCRRECT. <br />