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IFXAMPLE YIii� 1'; Com rehensive Trip Number ciw>N A os INSTRUCTIONS ON BACK O • P •NN 0l G1lrlOmla ART 2 DO NOT TAPE, STAPLE OR DUP CATE 420265 0 By signing this CA Comprehensive Trip Log and Receipt,the signer(s)request that the information provided on this form will be considered confidential,proprietary and trade secret. In accordance with Title,14 CCR,Section 17041 et seq.,If a request is made for disclosure of this information,the CIWMB will contact the signer(s)of this forth at the address and telephone number provided on this form or receipt Vehicle Information Truck Decal Number Hauler Address Fe LAM ,NU _Fl K c 5 a — a Business Name Address 3,dto. N c LA)II Sac,nWA-N,1W City, State and Zip License Plate Number State MENEEHN a ® � �af�TmCn �s to c�fio� CA y 5 2 s 1 certify under penalty of perjury under the Laws of the State of California that the information provided above is eue and torted.In addition,I am aware at fa talion of this i fo tion may result in suspension.revocation.or denial of renewal of Waste Tire Hauler Registration purwmH W Public Resources Code section 42950 and may result in civil penalties up to$25,000 per day,per violatio or ad isoalive penalties a$5,00 uviol day as described in Public Resources Code section 42962 Driver's Name printk5es Signature Da e Comprehensive Trip Log Number Load Information Facility Tire Program ID site Suffix omp Q ::202650 -- C Pick Up ❑ Delivery y g a D OE Facility Telephone Number Hauler Tire Program ID / Site Suffix DATE 0 / / w Whole Tire Count n Weight In Lbs. } cif yLei::mess CA-�Al'i'lU i j ~ Volume Cubic Yds.❑Weight in Tons lattl f`yddrWss y�y 7 0 . :: ;;:,, ;ity,$tate' "�.t zip () ` ' AK '] f/ .' 1Jf LCAT?i �s?. i- EDOO /`� AT-IFY Address Same as Hauler Iauler Telephone Number ■ mw s(N IA for THAT UNDER PENALTY OF PERJURY OF THE '- Whole Tires) U1W3 OF THE STATE OF CALIFORNIA THAT THE Y INFORMATION PROVIDED IS TRUE AND T. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 4202650 -- B ick Up ❑ Delivery Facility Telephone Number � 02Hauler Tire Program ID / Site Suffix DATE DE ;/ 2[] / -EpEpEEg UJ /Whole Tire Count Wight In Lbs. _r g � ity Business ( IW- y [ 3 C U 11 ~ Volume Cubic Yds. Weight in Tons zu)tae%AG ?r sS t 7 G o Hauler Names"fir; State nrld?i,,4 (.�/LGL✓E'Pi� f i l� lam' SjOCAIr'n C4 tzamp� I abv3^'�EEDEP-ou i Iauler Telephone Number ❑ Address Same as uler l Z, Initr Is /^ (N IA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Z O S / / Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE 1 to l/ INFORMATION PROVIDED A13OVE IS TRUE AND CORRECT. C Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 4202650 -- APick Up [g"Delivery 6 — 1 r� Program ID / Site Suffix Facility Telephone Number g DATE Hauler Tire Pro W Whole Tire Count Weight in Lbs. gtl�la^c�,c;g.L C}4 vel IDJ O dU I (� 9 ~ 1:1 Volume Cubic Yds. ❑Weight in Tons -".tTtpt . a.€r C "rl 211 N ',4auler Nasse L) CW k too " «65rp or Label t "(52o S a Address Same as Hauler --€soler Telephone Number ■ Inlfia I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Oct Jj J� ( (N IA for ) LAWS OF THE STATE OF CALIFORNIA THAT THE V L.{L+I..�`IY./.v Whole Tires) ires INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. F 7