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California Integrated Waste Management Boarig CA Comprehensive �p Log and Receipts P.O.Box 1259,Sacramento.CA 95812-1259 E X!, A M. P L E 1 �T� �a .- a = � Comprehensive Trip Number 5r cl—°` " INSTRUCTIONS ON BACK OF PART 2 D• NOT TAPE. STAPLE •R DUPLICATE 3096873 By signing this CA Comprehensive Tr.;.- _F.-:ahpl,the signerhs)req,est that the information provided on this form will be considered confidential,proprietary and trade secret. In accordance with Tine,14 CCR,Section 17041 el seq.,If a request is madr.ford;: _,. !-is information,the C77/M0 will contact the signer(s)of this form at the address and telephone number provided on this form or receipt. Vehicle Information I Truck Decal Number Hauler Address Business Name 0 ❑ - ❑ P n n ❑ ; �, 9 �� License Plate Number State Address ❑ a a a ® City, State and Zip '---�wv �c Cjq s I c ;ilr—:1 7nl C:h'V:- f—w-,proved P.d a:ro:e is If-and rrer:t In addhl— I ar,I--Ihal fal5i61a6o11 nlori mhon nay re-It n 5n ,1115ion. .ca dr•m,tl of rcnon.i:cl:�_ -„1,:i c I - t �, .r,,.i - - -,Cw.e -- d may result in c I;.r:hhan..,;.p 10 5:'S OUO per day.p.2,.„,Ion or aJhnnu lrahvr;..-t1�r.s up l0 55.11 0]lir ,rl;hl uhf ln.r hLry.I•,d rrihr•�I n P,..LI r Rese.•r« Driver's Name (print) Driver's Signature Date Q 3096873 __ C Pick Up Delivery ❑ ❑ ❑ ❑ ❑ ❑—❑ Hauler Tire Program ID 1 Site Suffix Facility N DATE Telephone Number ❑❑ / ❑❑ / ❑❑ a. 1:1 Whole Tire Count ❑Weight In Lbs. r [Facility Business F- Volume Cubic Yds. ❑Weight in Tons Name/Address � e d o City, State and Zip In Hauler Telephone Number F V � [][][][I Stamp or Label OK Q ■ n Initials THE Whole Tires Only ire Count _. .. CERTIFY THAT UNDER PENALTY PERJURY OF for Whole T LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. x 3096873 "" Pick Up Delivery Z a a M ❑ o-o a F1 1z ❑ ❑ a' Hauler Tire Program ID 1 Site Suffix Facility Telephone Number � DATEa� / H H-ER C W H ❑ ❑ ❑ oo a ® Whole The Count Weight In Lbs. g > Facility Business Volume Cubic Yds.[]Weight in Tons Name(Addresst-0-e-,ii-- m E City, State and Zip Z-3 ,__3 yHauler Telephone Number tj O Stamp or Label OIC `` � '" �CA 95330, 7� �1 y,/ Initials s (Z�L +1 �� _J - ^] Whole Tires Only t CERTIFY THAT UNDER PENALTY OF PERJURY OF THE for Whole Tire Count LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE ANn CORRECT. .Q .3 0 9 6 8 7 3 m® A k^ Pick Up Delivery 1 0 Hauler Tire Program ID i Site Suffix Facility Telephone Number DATEa� in a �� ®Whole Tire Count Weight In Lbs. EoIcIl-000aoo ❑ > Facility Busin^ss _ C) t f- Volume Cubic Yds. Weight in Tons Name/Address E City. State and Zip v y Hauler Telephone Number cry U � Stamp or Cabal CK r � I Q Initials C ( 700 Whole Tires Only I CERTIFY THAT UNDER PENALTY N-PERJURY E THE for Whole Tire Count LAWS OF THE STATE OF CALIF IS'A THAT THE INFORMATION PROVIDED ABOVE 1�T,2'JE AND CORRECT.