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: CA Comprehensive p Log and Receipts Dept o}Resources RocyclnpnndR2-12ry <br /> 1 2 P.O.Bax 1258,Socromento,CA 85812-1259 <br /> ,�R@CyC�B EXAMPLE 12.. 3 <br /> Comprehensive Tri Number; . <br /> Sr `'a°ro.W503765 <br /> INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR.DUPLICATE <br /> By alpnln0 W.CA CompreMnslY.THp loo and R—Ipt.the alpnerfe)rapuea)that th.tMf6nTW1on provided on this form will be eonsridered w f1dentlet,"privtery and trade 9*ere1.In accordance with Tide,14 CCR,5e Wn <br /> 1T011 et nap..N a rapueet Is made for dlwWo v of the Inlormatlon,CatRecycle W4 contact"alpnrrW of thla Corm at Uw adarvu and leiaphono number provided on tM a form or receipt. <br /> Vehicle Information <br /> Hauler Address <br /> Truck Decal Number v` �C t Q <br /> Business Name � S <br /> Address U,) . �!O S Cwl l�� G1 V Q_ <br /> City, State and Zip 'n,� <br /> ! mbar Stateav , <br /> License Plate Nu �a e <br /> V V` L� C—U C <br /> Com® D. �. ®.®•®' © .� �. Car eronL . _. <br /> I CM10Y orad,t.'Wty of pwlu•y under,lw wa rA tTr", <br /> caidoma that the"o—twtion pro-0ad ebmit fu true and correct In edatlort I em ,hal faeTB WI., NatW fnay nsttt H ,rarvcatk n,a dental of rwwwtJ 01 <br /> eho Ylaate rn auI epa,raton pun to 11p Code ,on algae end y rl>SUIt u+ch u penexiw up to$IS,OI)D Per Der bra a adminlaV a pwnert v (5.000 vloM, day u dwa+t»d H Public Raaouroes <br /> Code cecdon BBI J <br /> �v.i i Y <br /> Driver's Name tint _ Driver's Si nature Date <br /> Comprehensive . Log Number Load InformationProgram <br /> 5 G3 7556 =- C Pick Up--, Delivery' <br /> Hauler Tire Program ID /..Site Suffix. DATE Facility Telephone Number , <br /> . • . 00 oPaoPs.. <br /> w Ma0 <br /> � w Whole Tire Count Weight in Lbs. <br /> ', [Facility #10 <br /> 5 / Volume Cubic Yds. Weight In Tons Name'/ -t-. <br /> ouler Name / City, State'7f 00)Stoektoil Blvd. <br /> U V Stam§ � ta;��, 95823-39 .7 <br /> ■ Q Address Same as Hauler A <br /> Hauler-Telephone Number In r <br /> n �, (N/A ole i I CERTIFY THAT TAT ER PENALTYCALIFORNIAPTHAT RYE THE <br /> LLJ•-y(-�'J Whole Tirob) uW80F THE STATE OF A�IFOMTHAT THE <br /> INFORMATION PROVIDED A8OVE IS TME AND CORRECL <br /> aaa <br /> Comprehensive • •• Number LoadInformation <br /> Facility Tire n • • <br /> n <br /> 5037556 -- g Pick Up' lbelivery <br /> � ���F"'---a---c���ility Telephone Number <br /> V Hauler Tire Program ID / Site Suffix /EE / / / ZR <br /> wo -E] Whole Tire Count Weight in Lbs. .. <br /> {� S .� <br /> g I5' 3151 11 Volume Cubic Yds. Weight in Tons -7 dr <br /> to <br /> 0 aider Name ( �C <br /> t 1 eTOK �CC <br /> H u r Telepho e r _ ■ Address Same as Hauler. • „ fnl tau <br /> N/A tor,r I I CERTIFY THAT NDER PENALTY OF PERJIIR'r OF 7HE:•��,�� ti-- ,_• <br /> . / �„• J •� '` _. Whola n I,AYlS OF THI BTATE OF CAIJFORNIA INAT TNE- r:t j',• r <br /> 81F0R7•MM PROVIDED AEOVE fS TRUB ANO CORRECT.'. •a <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site SLIff iX <br /> 5037556 -- A f Pick Up : . Delivery o a o P Q F11 R-rUIR. <br /> U _ <br /> d Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> DATE <br /> • H-E 9,- ©®laaoo.� <br /> w�� Whole The Count 0 Welght In Lbs. <br /> Facility Business <br /> /" C C Volume Cubic Yds. 11 Weight in Tons, Name/Address <br /> o aider Name CPIC K-N=PULEiAUTO DISNL#3010 <br /> 7600 Stockton Blvd.. <br /> rn Stamp c ' -,^ <br /> Sacra� medto,CA 95823 <br /> Hauler Telephone Number Address Same as Hauler rnftlore <br /> ( (NIA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> /�/ , �'LL7 l/ /, Whole Tim) lAWB OF THE STATE OF CALIFORNIA THAT THE /ti <br /> `.. INFORMATION PROVIDED ABOVE 18 TRUE AND CORRECT. <br />