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GlNomla IRtegrated Waste Management Board <br /> CA Comprehensive Trip Log and Receipts 10002. P.O.SO=tug,saOre,eento,CA9=2' ,meg <br /> [IEIXIAIMIPILIEI 1112131Com rehengsiver�Tri Number <br /> cnwe'twjtnosl INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE 3 4`+O 2 4 <br /> BY.I�Inp m cA Domp.Iwnaln rnp Lap•nd RAe.IpL ur yvM•al,..�.e tNt IM lma,m.nm prarMtl on InI.Arm wn a emydwtl ca+ma.mm,prOgaary•tl b•d•P•a•i N•Coordavq•wm nn.,a ttR,9•cnpn <br /> 1 TDr/.M••ry,d•r•ewat M Intl.b dlacbu.•a W a InfarnuUon.Na CIW MB w0 canacl nu slpror(F)al Int.bm y vu•tlr•o•tl bleptvu number prOHdtl an tlur Lanni w nolpl <br /> e c e n or atLon Hauler Address <br /> Truck Decal Number I Business Name itCAri I Nb ,1 Vt <br /> Addresstt . <br /> City,State and'Zip _r!1!O <br /> License Plate Number State <br /> Common <br /> Carrier' J <br /> I '_FY al'M'undo,Ola lava W Oro Sura W CaiibrNa Nal Ne Information P,arMtl•bav M bli•and mn•a In WdW—I Am•vwn nut bbintaaon A tnY Ylbnn•IIPiI mry roup M aapwuluL n vtaaNt o,dawl of rei of UM <br /> Ways TVs M *Rapuaa punw W m Pi011c RI­Cone aamo�01960 a„tl avY­4b CMp•rWdPF W W E 75.000 pa.day.pa,Ndatlpn ar'20."'.pMltlp up b 35.000 qr vIplEUan D•n a.y a d•FOM•d In W We Retauof <br /> C� 42962 <br /> "08199071.46.2 <br /> Drlverte Name print Driver's Signature Date <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> a 3440.248 == C Pick Up: "�, eNvery � N <br /> U -® <br /> 1 Hauler Tire Program•iD"/ ,Site Suffix Facility Telephone /N-umber <br /> DATE <br /> W w �]4hole Tire Count 1Nelght In Lbs. <br /> ao� 000©o ©o <br /> Q. Facility Business 1 <br /> C] Volume Cubic Yds.❑Weight In Tons Name/Address, <br /> City,S to an zip' <br /> E <br /> Hauler Name �i� 11 <br /> Hauler Telephone,Number, � Address Same as Hauler. <br /> -' (N/A 10r I CERTIFY TMAT UNDER PENALTY OF PERJURY OF TME <br /> ..: <br /> To,, <br /> L ,,�t.�N �-1�{ • _ I LAWS OF TME$TAtE OF CALIFORNIA TIUT THE NA <br /> ✓� r VVV�a Whole Tires INWS OF R D AB JFO1U A TIR AMD RECf. ,\J,A�`r'aja4 <br /> ati <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 34402 4.8 -- B Pick Up D Delivery © a © [A a © N>-[T t� <br /> Hauler Tire Program ID / Site Suffix a© a� Facility Telephone Number <br /> - � DATE , , . a:a a a a a <br /> c Lu l�Whole Tire Count O Weight In Lbs. <br /> Facility Business tL�I rJZl •; ^'y�� <br /> I S Gj 9 (� 'a Volume Cubic Yds.❑Weight in Tons Name/Address- <br /> E .City;State and Zip _X.96 '7�Ia <br /> U) Hauler/N��a,m�,e 1- ,QjT b f OrJ .op". )jZ05 <br /> eIL Uri �)1�('s :Stam or Label OK / <br /> U Hauler.Tele hone'Number , a� ON�� O•AddressSameas,Hauler. 7aiusrs <br /> p 4' (N/A for I CERTVY THAT UNDER PERNLTY OF PEIYYRY OF THE <br /> W1101e Tim) LAMB OF THE STATL OF CALIFORNIA TNAT.TME <br /> ��•�. '��• `�•� '9eRRa'Y•" - INFORMATION PROnDEO ABOVE a TRUE AN0 C0-ALrt <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 3440248 -- A 11 Pick,Up aYDelivery 000000 [l <br /> -� L ti <br /> Q, Hauler Tire Program ID / 'Site Suffix Facility Telephone Number <br /> y, ti DATE on / ooa-a000ao <br /> t� <br /> w Whole Tire Count E]WeightIn Lbs: t <br /> o Facility Business <br /> m I ❑Volume Cubic Yds.a Weight In Tons Name/Address <br /> E Hauler Name <br /> City,State and Zip <br /> Stamp or Label OK <br /> Hauler Telephone NumberAddress Same as Hauler Initials <br /> . (N/A for I fEATRY TvILT uNDER PENALTT'DF PERJURY OF THE .. <br /> . Whole Ties) IAW3 OF TME STATE OF CALSORNu THAT TME <br /> MFORMATIOWPROVIOED ABOVE r9 TRUE ANO fONRECT. <br />