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j Dept of Resources Recycling and Recovery <br /> CA Comprehensive ip Log and Receipts •1 2P.D.Box 1259,SIiornmento,CA95812-1259 <br /> Com rehensive TripNumber <br /> CWR6Cy* E I X I A IMI P I L I E I I 12 -3 hh ss <br /> cal INSTRUCTIONS ON BACK OF PART 2 .DO NOT TAPE,STAPLE OR DUPLICATE V 3'75 J ' <br /> Dy.1p ninp this CA Compmhenalv.Trip Log and Rocrtpl,tlu 119ner(a)roqu"l Omrt"Intonnomon provldod on thls form will be conatdF.d oonndonUal,proprietary and trod.a►u.t In socord—with Tli1.,14 CCR,R.ctlon <br /> 1'1611 H a.q,M a ro9rMq le nude for tdeclaaaro of lhts lnfofmabon,Calfiaycla will contact the ol2nwp)of thlo to—at the addrou and W ophona numbs prodded on thhj rm or realpl. <br /> Vehicle Information <br /> Truck Decal Number Hauler Address, �� 61 <br /> nn Business Name /" <br /> Address s <br /> City,State and Zip 9O•�. � . � �\� � �� a�f2 <br /> License Plate Number State <br /> - <br /> Common. �Glvc CG <br /> ® aa � o ® a oa DCarrier <br /> •I comfy trdw peralty of por)iry undo th laws of tfa o of Ca:Noinla that the Information above is Uus and carred in addllot,I aware that fa!NGca of tab I :m mry MLA N►uepwa:on,revoutlon•w denial of rarmai o! <br /> the Wmle The W.fieglal,•stwn Ito Pubac un;p Code tion 42A30 and refutl In ctrl panahlea up to S 25,000 pr d pe vies=qn a eMrirua tiro pcf en up to RS,D00 ar vldatbn rdoy at oeecrlbod h Public Roaotxcae- <br /> Code aa:li 42 , <br /> .'Driver's Name Tint Drlvar's Si nature. Date <br /> id <br /> • • • • Program <br /> 5.Q 3,7.5 5.$ _., Pick Up Delivery <br /> •� _ . . • . D D ® baa <br /> 0' 'Hauler Tire Program ID / Site Suffix /. j Facility Telephone Number <br /> DATE BE r <br /> •C Whole The Count a Weight In Lbs, <br /> 000- oaaao ® D <br /> MFacility Business <br /> I Volume Cubic Yds. O Welght In Tons Name e; <br /> Cit <br /> �FICrt-N PULL #10. <br /> c cuter Name y U ►71�OC�CtO <br /> � S o Blvd.�•: ..•�• . <br /> < sty acrAlzb6i tb, CA 95823-3917 <br /> ■ Address Same as Hauler <br /> cul ct Tele�h�a N�Vmje� niers '. <br /> 9(r (N/A for t CEtinFl TtAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) IAWD OF THE STATE OF CALIFORNIA THAT THE <br /> INFORWTION PROVIDED ABOVE to TF0IN AMD CORREC'i. <br /> a <br /> 5037558 B Pick Up 'Delivery <br /> Hauler Tire Program ID / Site Suffix DATE Facility Telephone Number <br /> cr W. OU �= �ao � ® ® a <br /> CalWhole The Count Welght.ln Lbs. <br /> Facili$MAMROCK RECYCLING <br /> y I Volume Cubic Yds. Welght In Tons Nam, ' FitCALIFORNIA •INC. <br /> DEE <br /> Hauler Name :city-4,0840 IALiTAMOt4T.PASS RD.' <br /> LIVERMORE CA 94560-9745 <br /> . <br /> 'tam1( 09),933r,9& 0 <br /> Hauler Telephone Numbs s E D.Address Same as•Hauler <br /> • (N/A for :I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> .. ;t ':•a .s'. r 'r • - Whole Tires) LAW`OF T1ihJ STATE OF.CAUFORidA THAT THE' <br /> _ - INFORMATIONPr46MEAABOVE W.TRDBAND Cpitil <br /> Comprehensive Trip Log Number Load Information Facility Tire Program <br /> CL <br /> 0 � <br /> 5037558 'm- A Pick Up Delivery <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> DATE <br /> • � a_2'Who1e The Count 11 Weight In Lbs.. <br /> F I' 11isire - <br /> ... -� Volume Cubic Yds, Weight In Tons STT e, V <br /> E Cq e fid':fp f �g <br /> 0 Hauler Name <br /> CCA q <br /> U � ' <br /> Hauler Telephone Number 1} ■ 0 A'ddress'Same as Hauler <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF C.ALIFORNA THAT THE <br /> 2 27INFORMATION PROVIDED ABOVE 13 TRUE AND CORRECT. <br />