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` Dept of Resources R - <br /> p Recycling and Recovery <br /> CA Comprehensive ' i Lognand Receipts P.D.Box 1259,Sacramento,CA 95812.1259 <br /> eEX A M P L -E 11 2 3 Comprehensive Trip.Number <br /> G81Rec cl ; t"DO NOT TAPE.STAPLE OR DUPLURdR mINSTRUCTIONS ON BACK OF PART 2 ICATE <br /> -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 <br /> 17041 et seq.,tf a request is made for disclosure of this information,CalRacycb wig contact the signers)of this form at the address and telephone number provided on this form or receipt - - <br /> ° 1"'1,17"k cleanfo`_ft ation r, <br /> `Hauler Address <br /> Truck Decal Number fT s 1i✓ G(h <br /> Business'Name <br /> Address d*,y <br /> City, State and Zip <br /> License Plate Number State <br /> DCommon . <br /> I certify under penalry.of perjury under the laws of the State of California that the Ofpmnetlon provided above Is true and correct.In addition.I am aware that falsification of this information may resufl in suspension,revocation,or denial of 2newal of <br /> the Waste Tne Hauler 'tration pursuant to Public R ume$Code sect 42960 and may result in civil penalties up to$25,000 per day.per Zowndmimstrativepanallies up to$5 per.violation per day as de bed Public Resoumes <br /> Code section 4 - .. . <br /> ,11 . <br /> Dn en's Name(print) Driver's Signature -. to ' <br /> Comprehensive Trip Log Number Load Information Facility Tire Program <br /> .4359 7 3 2 -- C ' Pick'Up Delivery <br /> Hauler Tire Pror ' ' ' Suffix Facility Telephone Number <br /> gamID /. Site , <br /> DATE <br /> M _ wa Whole.Tire Count Weight In Lbs. <br /> ® o © © ao ® ao <br /> Fa i� 'asiness 1 <br /> L I �I .l 1 Volume Cubic Yds. Weight in Tons N. t+1A dress <br /> m <br /> E Hauler Nam - , <br /> cIe.�r"�1 JSfO <br /> s St?� ore(6knfh �o <br /> . a <br /> Hauler Telephone Number Address Same"as Hauler Initials . <br /> 7 Y�/O <br /> (N/A for 1 CERTIFY THAT UNDER PENALTY PERJURYOFTHE <br /> /•l`1 6 6 Whole Tires) LAWS OF THE STATE OF CALIFORNIANTHAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> Q <br /> 4359732. -- B. r Pick Up Delivery <br /> a <br /> 0 Facili Tele hone Number <br /> U4) Hauler Tire'Program ID / Site Suffix p DATE as / a[A' <br /> �. a <br /> goo- 0o� � ® 0a <br /> a �;Whole Tire Count 11 Weight In Lbs. :. <br /> Fa ',�" uslness _ =fir <br /> �/ I . Volume CubiaYds. a Weight in Tons ;Naeldress <br /> fyiY1 _1 <br /> Ha�r Na e Cit5g tot '•Vh'S Qh`. . <br /> _ jcu S st'tfrlp.c�F � i .7(j� �/{ �5� % <br /> Hauler Telephone Number , a ■ Address Same as Hauler <br /> initials- <br /> (NIA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE - <br /> `�\"' /,/' - LAWS OF THE STATE OF CALIFORNIA THAT THE l <br /> '7� -e/�j/5_V O':•�2�a Whole INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suff ix <br /> 9 7,32 ' == 'A Pick Up � Delivery � � � ® rP E-® 0" <br /> Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix <br /> DATE <br /> � wa ® Whole Tire Count• � Weight In Lbs. <br /> Fa f y l Ms-ness <br /> 6 3 5 1 t _ 1 Volume Cubic Yds: Weight in Tons Na n r G <br /> Cit We 1 Zici Di f 0� ✓{.. <br /> . 0 Hauler Name I <br /> U <br /> Hauler Telephone Number, 0000 ■ Q AddreSla"IfOLss_Same.as Hauler ,,,;niers• <br /> •� �;� /r�� / ` (Nfor (CERTIFY THAT ESTATE F CALIFORNIA <br /> NI PERJURY <br /> YE THE" <br /> LJ 6 [D U Wholele Tires) INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />