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Cal <br /> ed Waste <br /> Board <br /> CA Comprehensive Trip Log and Receipts P.O. nial259,Sacramento,CA <br /> P.O.Box 1259,Sacramento,CA 95812-1259 <br /> <X A P I s Comprehensive Tri Number <br /> 1 <br /> SfaeO"""°"`' INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE <br /> 1 <br /> c',ma farosl <br /> By signing this CA Comprehensive Trip Log and Receipt,the signers)request that the information provided on this form will be considered confidential,proprietary and trade secret.In accordance with Title,14 CCR.Section <br /> 17041 at seq.,If a request is made for disclosure of this information,the CIWNIB will contact the signer(s)of this form at the address and telephone number provided on this form or receipt. <br /> Vehicle Information <br /> k Decal Number Hauler Address <br /> Truck - 11110 o Business Name <br /> License Plate Number State Address <br /> [10 11 [1 U U U Ll City, State and Zip <br /> I certify under penalty of perjury under the laws of the Slate of California that the information provided above is true and correct.In addition.I am aware that falsification of this information may result in suspension,revocation,or denial of renewal of the <br /> Waste Tire Hauler Registration pursuant to Public Resources Codesection42960 and may result in civil penalties up to S 25.000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources <br /> Cade section 42962 <br /> Driver's Name(print) Driver's Signature Date <br /> Q 310 2 812 -- Pickup ❑ Delivery a o 0 o a a 0-0 a <br /> 0) Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> N DATE oo / oa / o0 <br /> • 000-ooa000a <br /> M a ®Whole Tire Count Weight in Lbs. <br /> g r I Facility Business <br /> a- ® Volume Cubic Yds.®weight in Tons Name/Address <br /> d <br /> E City, State and Zip <br /> auler Telephone Number <br /> g Stamp or Label OK <br /> Q <br /> ® Initials <br /> Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> for Whole Tire Count LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> s • • • • .• s. e e e es <br /> 3102812 -- ts Pick Up ❑ Delivery oaaoaaa-oa <br /> DATE 0[] <br /> Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffixoaa-oaooaao <br /> e w ®Whole Tire Count Weight in Lbs. <br /> [Facility Business <br /> s- ® Volume Cubic Yds.®Weight in Tons Name/Address <br /> d <br /> o City, State and Zip <br /> fn Hauler Telephone Number <br /> Lj Stamp or Label OK <br /> 4 <br /> ® Initials <br /> Whole Tires Only I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> for Whole Tire Count LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> 3102812 -- Pick Up ❑ Delivery <br /> Pilo� Hauler Tire Program ID / Site Suffix DATE / / ity Telephone Number <br /> . oaD-ooaooa <br /> LU ®Whole Tire Count ®Weight In Lbs. <br /> } Facilit Business <br /> h ®Volume Cubic Yds. ®Weight in Tons Name/Address <br /> o City, State and Zip <br /> y Hauler Telephone Number <br /> 3 ~ <br /> V Stamp or Label OK <br /> a [][] oo <br /> ® Initials <br /> Whole Tires Only _ I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> for Whole Tire CountLAWS OF THE STATE OF CALIFORNIA THAT 7HE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> �,r <br />