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, , <br />Oa CA Comprehensive _. ip Log and Receipts . oopt'ofilewurco•Rocyctuyo aecovery <br />1 x RO. adx 12b8, 6ocrnmonto, GA 85612- 1269 <br />t;f� � y.. <br />Ca1Re�ycle E x A M .P L E'1112131• � ` r. m'• rehensive Trip/��gNumber <br />` R� J�37559 <br />w_7w(7 <br />" ngjINSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE <br />By signing this CA CompnhensNe Trip Log and RscelA the slgner(s) request that the V" metlon F—Wed on We form wt0 be cw.Jdand conAdential, propr4tary and ands scant In accordance tNRh Title, 14 CCR, Section <br />17041.61 aeq, if a realuesl Is made for dlsclown of this tnformaUon, C41RaCycla wsa conbct the aigner(s) of this form at the address and tsfapMn• manber provided on this fe" or mattpt. <br />Vehicle Information <br />Truck Decal Number Hauler Address C / <br />Business Name <br />Address 1 A r' a. id• '�j/ 1 \M 2 G1 ��. <br />a a ❑ City, State and Zip <br />License Plate Number State <br />M@11� EDE ED ❑ Came on L r. J <br />11.11, under permity of psrhry w4or the laws of Ute stat GJlfprnJa MI Uta J www on provided shwa Ia true and corral. In sd6ticrt, I om zr o that lalsifkal� Uds Wonna my mutt in wspansion. rev xW , w danal of ranewsf W <br />' tho Wast, Toe Hauler Ragtrtnton p—suanI Public R ss Cada acct 42gE0 end rnny In chnl penahise up to • 25,000 par y, vtplatlon w admin,*tr4ye P.I. up S5,00D per vro bre pa daY as dbed h Puhlc Ro cw <br />cods sactlon 42 1lVSI` Y. (`i; <br />.1 <br />.t <br />.Driver's Name (print) -,Driver's Signature ate" r <br />5-0375-59-- -- .(i Pick Up Delivery oil 0, D [I � ❑ — ❑' <br />Ra. <br />Iv• -Facility Tele Tran Number . <br />cc <br />Hauler Tire Program ID Site ffix ❑❑ / ❑❑ �'❑❑. p <br />_. .. r DATE <br />a © Whole Ti� nta Weight In Lbs. _ <br />tme <br />ity BusinessVolume Cubic Yds. Welght•In Tons /Address t <br />o Hauler Name I` City, State and Zip <br />U Stamp orLa <br />Hauler Telephone Number ■ D Address Same as Hauler nJ f <br />(N/A far I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br />{ Whole Tlr•o) U` OP TME STATE OF CALIfORNIA THAT THE <br />INFORMATION PROVIDED ABOVE 17 TRUE AND CORRECT. <br />Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br />CL <br />� 03 5 9 �- B Pick Up Delivery © ©� - DIS <br />Hauler Tire Program. ID / Site Suffix Facility Telephone Number. <br />. <br />_ DATE <br />� • w � Whole Tire Count � Wefght in Lbs. <br />g N M ` <br />Volume Cubic Yds. � Weight In Tans � r ss _ r Ss <br />o auler Name `' <br />Ci ah Zip' � ' s ��� `�(_ Ut <br />_- <br />r <br />U '� S Qin. st,-u �s <br />' Hauier Telephone Number ■ Address Same as Hauler r ren <br />(N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF TRE <br />• i - Whale Tires) LJIYYa OF THE STATE OF CALiFORNLA THAT THE , • ' . <br />INFORMATON PROVIDED ABOVE 15 TRUE AND CORRECT. <br />Comprehensive Tr• Log Number Load Information Facility Tire Program IM Site Suffix <br />5037559 -- A Pick Up EDeliveryt: 2. �. -' © a <br />0 x Hauler <br />Tire Pr. og- r.am: ID Site .Suff.ix <br />� Facility Telephone Number <br />DATE <br />D 00-Q 4 00©��1 <br />Whole Tire Count E]Weight In Lbs. <br />' Facility Business <br />a.— 0 Volume Cubic Yds. R Weight In Tons ' PiaXiLgclt}i-d0J_ AUTO DLS1V1.0010 <br />o H user Name City, State ;?MbPg ocliton Blvd. <br />�.0 v (U- &k y i (.-L-� I- Sacramento, CA 95823 <br />3 ¢ Stamp or.Label OK <br />Hauler Telepho ' Address Same as Hauler �f}�ry)�}� <br />(ole for I AWS O Y THAT STATE <br />PENALTY NI PERJURY OF THE <br />("' I Whole T1reUj LAWS Of THE STATE OF CALIFORNIA THAT THE <br />tNFOAMATION PROVIDED ABOVE 15 TRUE AND CORRECT. <br />