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Dept.of Resources Recycling and Recovery. CA Comprehensive. p Log-and Receipts = 1 o:B6x1259,Sacrairnento,CA95812=1259 Cal ReCyClc. E X A' M P L E 11 2 3 - Comprehensive Tri Number.. moo)INSTRUCTIONS.ON BACK,OF PART 2.'DO NOT•TAPE.STAPLE OR DUPLICATE•° _4946728 By signing this CA Comprehensive Trip Log and Receipt;the signer(s)request that the Information provided on this fort will be considered confidential,proprietary andtrade secret In accordance with TItIa,14 CCR,Section 17041 at seq.,N a request Is made for disclosure of this Information,CalRecycie will contact the slgner(s)of this fort at the address and telephone number provided on this form or receipt. -' 1/etiicl_51OR rmation Truck Decal Number Hauler Address Business Name Address ® © � City, State and Zip• License Plate Number State 2839 S.CHERRY Aur~ BI Id.ER R1.R. E - ki ®- 0'Car ern . �- FRESNO, CA :9370 I certify under penalty ofperjury under the laws of the State 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 Waste Tire Hauler Registration pursuant to Public Resources Code section 429860 andgmay result in.civil penalties up to E 25,000 per day,par violation or administrative penalties up to 55,000 per violation per day dascnbed i Public Resources Coda section 42962� � �G`�\\'�� -� $- _6:0'7 0 13 S 5... •` -:Driver's Name.(print) -•• - Driver's Signature , Date,',--.Comprehensive Trip . . Number Load Information Facility Tire Program a 4'.9-4 6_72 2 8 ❑ Pick Up. .Delivelry. :❑ ❑' ❑ ❑ ❑ ❑ ❑- Hauler Tire'Program ID :.,/:__Site_Suffix Facility.Telephone Number. DATE ❑❑ , ❑❑ ,:❑❑ ..: '0000000 . wa ❑ Whole Tire Count '❑ Weight in Lbs. g [Facility Business y El Volume Cubic Yds. E] Weight in Tons Name/Address o Hauler Name City;State and Zip . 0 Stamp or Label OK Hauler Telephone Number ■ ❑ Add00ress Sarime as Hauler . Initials (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE ' Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE , INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number Load Information' Facility Tire Program ID Site Suffix .T' x 4946728 -� B a Pick Up ❑ Delivery ! a a 4) Hauler Tire Program ID /' Site Suffix Facility Telephone Number c DATE ME / ® © a oa © ® oo wa�OWhole Tire Count ❑ Weight In Lbs. tt I t �' _ ' ❑ Volume Cubic Yds:❑ Weight in Tons �/ c Hauler Name41 a Hauler Telephone Number EOREE■oo, Address Sarne'as.Hauler f„dials_ 1 - '.� �• - - - ,I CERTIFKTHAT UNDER'PENALTY OF PERJURY OF THE- (N/A for _5(y/y(/��\ - Whole Tires)'• 'MAWS OF THESTATE OF.CALIFORNUI THAT THE. _. 1 `+ �/` 'INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program D Site Suff ix - .4946-72 8 —= .A , : ❑ Pick:Up Delivelly a o a o 0 Facility.Telephone Number Hauler.Tire Program ID /.'Site Suffix eep � - •. �: DATE aw_ Whole Tire.Count ElWeight in Lbs. Volume Cubic,Yds.G y ❑ Weight in Tons N rrlcJ� .1 �C E Hauler Name a. Hauler Telephone Number ■ ❑ Address Same as Hauler /rtltfaf8'l (��✓11 O�//� (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE J 1�- , '�•� T J{/� Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE ' l/V V INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.