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California Integratedwaste Management Board
<br /> :. . CA Comprehensive Trip Log and Receipts 10002 R.O.Boa,359,BacramenlD,cA95B,3_R59 -
<br /> EkX A1jMv P L E i _ 3 Comprehensive Tri Number
<br /> aw s;;t(aosl INSTRUCTIONS,ON-BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE 3231597
<br /> By elMing Ihle CA Comprehenahe THy LLop aM Recelpl In.FIV..n.)n9wa NatNa IW.—.-prwlded on Ihle loan will M consl—d conRdentlel,propdoUry and trade.....1.In eoc ordence wile Floe.14 CCR,B Uon
<br /> 11.1 el eeR.,It•r ..M 1,made Io,di.d. n of.1.Inf—Uon,Me CIWMB will contact me alpneHe).1 DIN form D the eddnee no telephone I,—,p—Id.d,n thle form or receipt
<br /> Vehicle Information Hauler Address �c
<br /> Truck Decal Number Business Name
<br /> Address 0 O. g U
<br /> City,State and Zip 7<'a G,I I CAS 3-79
<br /> License Plate Number State
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<br /> I—1y enter p.nelry of p.,,,coda the laws of Irw sola a Caluomla mal th mlprmelwn pro,—8—b aue and Dw.erd.In addW,I am aware lnerf,Wfi,aDon of mn.form—may—11 m¢aapene�m,—n.or d.nml d rer«,wa of
<br /> Waste lira
<br /> Hauler Rogistr—pursuant to P-1 R—rces Cod,ee —4$960—may—A.,c,I penalties up to$25 00D per Cay,per—,Don w adminlaDeWe11,91 up 10$5,000 Dar-Nda4W per day ae doanloed.,P—R-1—
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<br /> Driver's Name print Driver's Signature Date,
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<br /> '3231597 00 C Pick Up � Delivery
<br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number
<br /> DATE Do /
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<br /> Whole Tire Count1:1 Weight in Lbs. a a o a a a a
<br /> 2 I Facility Business
<br /> y Q. Volume Volume Cubic Yds.E]Weight in Tons Name/Address
<br /> Hauler Name
<br /> City,State and Zip
<br /> Ua aaaoa oo Stamp orLabel 06C
<br /> �7elephone Number ❑ 0 Address Same as Hauler Mifi.k
<br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE
<br /> Whole Tim LAWS OF THE STATE OF CALIFORNIA THAT THE
<br /> ���p�p���ry��y� ��p����/ INNFORMATION MO—F.ABOVE IS TRUE AH ORRE
<br /> •_ a e�' ,,..W'L@9""_ L'i:rC.l°l IlR1AJ1711UL•/91°.UII IYQ U Wl� C11_l"y CA!'..VUES
<br /> 3231597 Ck Ups ffDefivery
<br /> Hauler Tire Program ID / Site Suffix Facility Telephone,Number
<br /> � r ..
<br /> DATE
<br /> �� /
<br /> a Whole Tire Count Weight In Lbs.
<br /> a Facility BusinessT'rC, c`1
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<br /> 11 -4-1 p y 1 0 ( E Volume Cubic Yds. Weight in Tons Name/Address �� a r
<br /> E Hauler Name City,.State and Zip 3030 3
<br /> a oaaoo oa SItit�G a�th�
<br /> u 7(-c,c.� �4e1 D: 5G 1 O Stamp or Label OIGTra cyl CEi•ej5 37 7 I _
<br /> ulerTelephone Number ❑ Address Same as Hauler na/ab. J
<br /> —O li h IA for I CERTIFY HE UNDER PENALTY NI PERJURY Df THE
<br /> r� tO l/ Whole TlrOe) LAWS OF THE STATE OF CALIFORNIA TNAT THEO.
<br /> I 1 FORMATION PROVIDED ANQVE 14 TRUE AN CORRECT.(�y�(�,� .,
<br /> ••"""'••""•..•• ll,°.CJJ° LL/UJ.°.IIIAJlC11/°.Ull � ep OD C.11.Sd G�LUIPS
<br /> 3231597 Q L'ocCi up Delivery 9*1<21 H n-
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<br /> Hauler Tire Program ID / Site Suffix DATE 1 / U Facility Telephone Number
<br /> _ gao T oa �
<br /> ww Whole Tire Count ❑Weight In Lbs.
<br /> [—Facility BusinessT-e IL
<br /> y O `P E� U I Volume Cubic Yds.[]Weight In Tons Name/Address c�g Ce tJ c� �t
<br /> E Hauler Name City,State andZipzGOGjgs.r�GLp`�'µ
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<br /> TSG �e��G OSS+ 1 ~ Stam or Label OK ��� �S3
<br /> u.IerTelep3 r fVujnp ❑
<br /> Address same as Hauler
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<br /> IN/A for I CERTIFY THAT UNDER PENALTY�E�UEU. /
<br /> Whole Tire.) —OF THE STATE OF CAUFOR
<br /> INFORMATION PROVIDED ABOVE IS
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