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j Dept of Resources Recycling and Recovery <br />•�':'i� CA Comprehensive ip Log and Receipts .t 2P.D. Box 1259,a6ornmento,CA95812-1259 <br />Com rehensive Tri Number <br />CWR6Cy* E I X I A IMI P I L I E I I 12 -3 h s <br />r �� INSTRUCTIONS ON BACK OF PART 2 .DO NOT TAPE, STAPLE OR DUPLICATE _ V 3'75 J ' <br />By alp nine this CA Compmhenelve Trip Lop and Racstpf, e» 119nee(e) requasl Um t"InIonrunion provided on this form will be consklered oonndanUel, proprietary and trade s►crat In soaotdanoe with TIUe, 14 CCR, SecUon <br />1'1611 H aeq^ R • raqueq le nude for tascloswe of this lnfornuUon, C•IFlerycla will contact the elsnerp) of thls tone st the eddrau and telephone nurm mber provided on this] of recelpL <br />Vehicle Information <br />Truck Decal Number Hauler Address,��61 <br />Business Name /" <br />a 14 Id 161 [A ® - ® <br />License Plate Number State <br />Ra.E� 2_a <br />I cemfy Irdw peralty of IMrlw undo* th}} taws 01111* cNo <br />a o1 Carnla that ftlrfornuti <br />the Wmle Tire H+�W. Replsf.•.tr prra ,I to Pubes urca Code t1lon 42W vrcl <br />Code "clips 4^ 1` <br />Driver'sVane (DrinO <br />.9--5.0 3.7558,-.,--.C..._ <br />U <br />Q- :Hauler Tire Program ID / Site Suffix <br />cc <br />fo <br />0 auler Name <br />uler Tele hone NQmneh <br />y� �23 <br />5037558 -- B <br />Hauler Tire Program ID / Site Suffix <br />c <br />Cal <br />c . <br />2 <br />1. <br />Hauler Name <br />X ll <br />' I ki <br />Hauler Telephone Number'• <br />5037558 - A <br />Hauler Tire Program ID / Site Suffix <br />I' � <br />Hauler Name <br />U <br />Hauler Telephorie Number • <br />Address r - s Q �1� a viz <br />City, State and Zip <br />0 - CC,A' . �Gvc C <br />Carrier <br />above i1 We and tar•cL in addim, I aware that fa±alfx;a of this I tm mry raeuA N alnperu:on, ravoutlon, w denld o! rw,ew el u! <br />rafull In olvI panahiea up to S 25,000 pr d , pe vloo:gn a edmiNl fl- pen up to SS 000 r vlot.T", <br />ti oescrlbed In Public Reeotxcee - <br />. . • . Driver's <br />Pick Up ' I ' Delivery <br />DATE � � / � ®/ � �, I► <br />W. n- Whole The Count a Weight In lbs, <br />Volume Cubic Yds. 0 Weight In Tons <br />P. <br />(N/A for <br />Whole Tires) <br />s. r <br />Pick Up Vj'Delivery <br />DATE <br />Ly -E] Whole Tire Count [jWelght.ln lbs. <br />Volume Cubic Yds.. Weight In Tons <br />(N/A for <br />. _ Whole Thee) <br />Date :I <br />Facility Telephone Number <br />000--oaaao®� <br />�4 <br />Facility Business <br />tyr Pli(e- -N-PULL #10. <br />9tockto <br />o Blvd...'..-.;.. : :;•'. <br />Sty acrAlzb6iitb, CA 95823-3917 <br />Address Same as Hauler nrpra '. <br />I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br />LAWS OF THE STATE OF CALIFORNIA THAT THE <br />ormw <br />Facility Telephone Number <br />OIN 4- 9N H RE E E <br />Facili$MAMROCK RECYCLING <br />Narric' EtCALIFORNIA ANC. <br />PASS RD.' <br />LIVERMORE CA 94560-9745 <br />Address Same a§ -Hauler , <br />I cERnFY THAT UNDER PENALTY OF PERJURY OF THE <br />LAWS OF THE STATE OF. CALIFORItlA TTUT THE - <br />INFORMATION PROVIDED ABOVE I11-TRt1E AND CORRECL <br />Pick Up J Deliveryl Ul � Irl N I/ u I m A <br />2.2 Facility Telephone Number <br />DAT <br />E%a�/�� <br />a_Qi Whole The Count � Weight In Lbs.. �e�- <br />�v�F]F 1 si we' <br />Volume Cubic Yds, Weight In Tonsrt,g�VNeGq.��►A f v <br />I <br />■ 0 A'ddress'Same as Hauler <br />(N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF TH£ <br />Whole Tires) LAWS OF THE STATE OF C.ALIFORNtA THAT THE <br />INFORMATION PROVIDED ABOVE 13 TRUE AND CORRECT <br />