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Dept:of Resourcos Recycling and Recovory <br /> CA Comprehensive p Log and Receipts 1 z P.O.Box 1269,Saerarnonto,CA 95812-1259 <br /> CelReeycle EXAMPLE 1 2 3 <br /> Comprehensive Trip. .Number <br /> ; ,;�," (716 INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE . <br /> BY signir9 this CA Compryhonshe Thp Lop and Recelpt,the signor(.)rvqueat that the Iwormatlon provided on this farm will be conwdomd cnnrldantlat,proprivi q and trod.secret.in.coordxncs with nos,14 CCR,(Tetuan-. <br /> I T041 et seq.•if a request Is mado for dl sclaaum of this Intortnatlon,CatRscycb It contact the slonor(a)of this form at the addroU and Wapho"number pmvid.0 on if,la toren or mcs;pt. <br /> Vehicle Information <br /> Truck Decal Number Hauler Address .Business Name � J\ 9-5 <br /> - <br /> _ ® � Address <br /> D ® 0 City,State and Zip <br /> Ucenss Plate Number State L'C_C.t CG, 'tet S 3 <br /> a ® � 2 U -10 Carrier L <br /> I <br /> cad it;undo,Pon of pejury under I laws of the Stat t C.Itforn!a that the Information molded oboe.b L'Vs"coned,to ad tion I�WWQ.move fakC,ca'on of W ormaC result In moa ,revocation•or dental a(rano ral of <br /> Ihe Waste Tits Hader Rogistr.I.on Purs�Fo` <br /> Cods +on s2•CO srW rsadt N call penalties up to S 25-00 pa WY,pert vlO4 a uNnnlstmI- as up I ADOZler <br /> day m de"bed In f wt W Raaotrcoe <br /> Cab sect a 1111` <br /> -� I c, , <br /> Driver's Namejurinil Driver's Signature Date <br /> Comprehensive •. Number Load Information Facility Tire Program <br /> Q Pick Up ---'Del ry` — <br /> Hauler Tire Program lD / Site Suffix Facility Telephone Number <br /> DATE Facility _ <br /> _ moa Whole Tire Count Weight In Lbs. <br /> 1cVolume Cubic Yds. Weight In Tons nt <br /> t <br /> auler Name Q�` �..YV`\ �e-- <br /> U l ! 3 S c a CA CC{ . `�S <br /> Hauler Telephone Number ■ Address Same as Hauler., Inlrlala <br /> ^� n - (ole for (CERTIFY THAT ESTATUNDER PENALTY <br /> ORNIA THAT RYE THE <br /> C,V/,1)\ f <br /> Whole Tlrof) ,�W8 OF THE STATE OF CALJFORxIA THAT THE <br /> INFORMATION PROWDED ABOVE IS TRUE AND CORRECT <br /> a <br /> Comprehensive Trip Log Number Load Information Facility Tire Program <br /> Q <br /> 5037551 ^^ B Pick Up Delivery <br /> ami Hauler Tire Program ID / Site Suffix � Facility Telephone Number, <br /> � DATE ®��� ®LLJ •%� � <br /> r Daa - o ® aao � <br /> � w Whole Tiro Count � Weight In Lbs. <br /> FacilityBusiness <br /> J I Volume Cubic Yds• Weight In Tons Na a _� L AUTO DISM.#3010 <br /> oHauler Name Cit , orate 7wdg'tocktonBlvd. <br /> 3 \A C� � ` � 1�Q HEStamp or SaCr`81mUf tiro,CA 45823 <br /> V Address Same as Hauler:, rtk,al �� <br /> H uler Telephoney Numb I .�,•.•,, ICE�RTIFY 1.UNDER PENALTY OF PE RJURY OF THE, <br /> �[� . y ., (NIAole for ._ <br /> t <br /> Whole Tlrotlj t• LAVIO OF THE STATE OF CALIFORNUt THAT THE _=s •,; <br /> WfORAIATIDN PRWA=ABOVE 98 TRUE AND QMEa.. <br /> Comprehensive Trip Log Number Load Information Facility Tire Progra'm ID Site Suffix <br /> 5037551 a-- A Pick Up f 'De-livery.. as <br /> D <br /> Hauler Tire Program ID / Site Suffix I. Facility Telephone Number <br /> � DATEMEE <br /> c - w Li Whole Tire Count Weight In Lbs. <br /> C (—i�l}Fusi }:, X14 Q_r t at`/ <br /> fI ? 0 Volume Cubic Yds. 0 Weight In Tons. I al T�/lade rel? /c� <br /> oa ler Name I \` n ' �> <br /> U �t v tof mp or Label OK <br /> Hauler Telephone Number ■ F� Address Same as,Hauler itrdr <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE / <br /> t�I Whole Timm LAWS OF THE STATE OF CALIFOR"THAT THE <br /> /-� <br /> Y�--� / [,� L v I INFORMATION PROVIDED ABOVE 13 TRUE AND CORRECT <br />