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: CA Comprehensive p Log and Receipts Dept o}Resources RocyclnpnndRoco12ry <br />1 2 P.O. Bax 1258, Socromento, CA 95a12 - 1259 <br />W�yd8E X AMP L E I 2.. 3 Comprehensive, Trip.Number; . <br />St.* of503755 <br />ON BACK OF PART 2 DO NOT TAPE, STAPLE OR.DUPLICATE <br />tary and trade aeet. In ordarw. withTide, 14 CCR, 9.cWn .. , <br />By *Ming W. CA Comprehend—Trip Log and R-1pt. th. 09ner{e) rapuea) that th. WOM-111— prwWd on thb form will be conalde d wmidentlat, "prMrecc <br />1T011 et 110%. N a rapueet Is made tw dkctown of thle Information, CatRecycle wttl contact" alpnerW of thla Corm at Uw adomu and Iataphono number provided on th!a form or me.lpt. <br />Vehicle Information <br />Hauler Address ` 1` �� ` C <br />Business Name V �V <br />Address 1107 U,) , \/ O S Cwl l"�� G1 V Q_ <br />�7 <br />Truck Decal Number <br />_ <br />City, State and Zip ! <br />CCommS <br />! Number State <br />License Plate Nu <br />t`_�a e <br />� Q�_ C—U <br />® D. �. ®. ®• ®' © �. <br />.. . <br />.� <br />Carrieron.�.. <br />1 cath under pa'wty a pwlu7 under ,lw we W o+e to of CaGdoma that the Narration Provided &W o fu true and Correct In eda Im I em ,hal fatatnealax, fhb k# fray resift H , mocatk n. a denial of rw "41 of <br />the w&VO Tn 6Vi OQa,ri1M pun to PUOGC p Code bra a19eo end y rNWt rn c" ParaAJ uP tV $ 26 O00 per per bra a adminlafre Oenex V 55.000 vlobf day u ctWarboo In PtAac Raaouroes <br />Code cecdon Bel ) - <br />Y <br />Driver's Name tint _ . Driver's Si nature Date <br />Comprehensive . Log Number <br />Load InformationProgram <br />5 G3 7 5 5 6 =- .0 <br />Pick Up--, Delivery' <br />Hauler Tire Program ID /.. Site Suffix. <br />DATE / <br />. • .00 oPaoM�.ns.. <br />Facility Telephone Number <br />a F P- P o �. <br />Whole Tire Count Weight in Lbs. <br />ElVolume Cubic Yds. � Weight in Tons <br />w <br />_ �w <br />', <br />% <br />[Facility #10 <br />Name/ <br />ouler <br />U <br />5 <br />_ L. <br />City, State 7 00?Sto ktoil Blvd. ' • <br />Stam§�ta; ��, 95823-39.7 <br />Name / <br />V <br />' ■ <br />(N/A i <br />Whole Tiroe) <br />Q Address Same as Hauler In r nt <br />(CERTIFY THAT UNDER PALtt CALIFORNIAPERDU RYE THE <br />uW80F THE STATE OF CNTHAT THE <br />Hauler -Telephone Number <br />LLD•-y(-�'J <br />INFORMATION PRO1VMD A8OVE I8 TME AND CORRECL <br />n <br />5037556 -- g <br />Pick Up' lbelivery <br />�F'-a-c�ility <br />� <br />Hauler Tire Program ID / Site Suffix <br />/ EE/ / <br />/ ZR <br />Telephone Number <br />.. <br />wo -� Whole Tire Count Weight in Lbs. <br />g <br />I5' 3151 <br />O Volume Cubic Yds. Weight in Tons <br />_. <br />{� S .� <br />-7 dr <br />auier Name <br />o <br />to <br />( �C <br />t 1 eiOK �C C <br />c' <br />■ <br />JNA for, r <br />'` _. '. Whole Tiro,) <br />Q Address Same as Hauler. • „ 1n,,,,, .. <br />I I CERTIFY THAT UNDER PEHA 7 O PERJIIR'r l 7HE:•��, �� ti-- .; ,_• <br />lAYl8 OF THEBTATEOF CAIJFORNIA (NAT TNE-;-�:tj',• <br />• a <br />H u r Telepho e r _ <br />�( ./�/.rJ�/ <br />.„• J •/ / <br />- <br />94FOfUlM M PwwtfIFD A60VE tS TRI1B ANO CORNEC�.'. <br />Comprehensive Trip Log Number <br />Load Information <br />Facility Tire Program ID Site SLIff iX <br />a <br />5037556 -- A <br />• <br />f Pick Up :. Delivery <br />o a o P Q F11 R-rUIR. <br />U <br />d <br />Hauler Tire Program ID / Site Suffix <br />DATE /©/ a© <br />(�a <br />Facility Telephone Number <br />_ <br />RE 91 -PEEN <br />w�E Whole The Count O Welght in Lbs. <br />-RHE <br />Facility Business <br />/ ” C C <br />Volume Cubic Yds. Welght in Tons, <br />Name/Address <br />CPIC K-N-,PULEiAUTO DISNL #3010 <br />o <br />rn <br />auger Name <br />G) 0 ��' <br />7600 Stockton Blvd.. <br />Stamp c ' �h_1 <br />Sacrame^&, CA 95823 <br />1 <br />� Address Same as Hauler rnftlPre <br />Hauler Telephone Number <br />( / ,� �%'7 / <br />l <br />('1/A for <br />Whole Tim) <br />I CERTIFY THAT LINTER PENALTY OF PERJURY OF THE <br />(AWB OF THE STATE OF CALIFORNIA THAT THE / ti <br />TRUE AND <br />`.. / L /, <br />INFORMATION PROVIDED ABOVE 18 CORRECT. <br />