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Toll Free *6-896-0600 / www.calrecydcle.r ov/Tires/ <br /> Dept_Of Resourced Recycling®tW Raeovarp <br /> i CA Comprehensive Trip Log and Receipts 10002 P.o.Box 1259.Sacramento,CA 05812-12W <br /> -. Comprehensive Tri Number' <br /> CI 1RBGyCIC �E�?C�A M P L L 1 2 3 -` --- r 47363 <br /> ~� <br /> r'w" n�INSTRUCTIONS ON BACK OF PART 2 D d PE T PLE O DUPLIC�TE LBy aF3ninu tht.CA Cor*mrebonxNa PIR Lop and R—'Ili,the 11110"(.)1equ"1t II am Iha Inlnmrblmn pmNdW nn 11,1•Inns wdl tw..10.111•.111 conddrrnU.1,prupnalnry nnA hal"aacrnt.h,,mr",dao a«.m nHe,t o CCR Hon <br /> 1.1x1 tl...tl.tf n inq�.of Is nurdn 11r 111.losuro of Ihln In+nnnnllnn,Cnlll"c YCln wIII Lnnlncl ll,•al{11"I(N 1f UHa I111n 11 Ire•nddraas nnrl telaphn,a lumber Pr—Id d nn rtdv Inrm ur rer,eipl. _-... �• I <br /> ynhicle Intorrnotlon <br /> Tmck Decal Nurribcr <br /> Ill L°1 OZ- <br /> Lfcflf <br /> ve"�.daT <br /> ISP,Ffate P•lfltntft _ ",1;11e I <br /> q 2 D f <br /> [A] ,LG I Ed W [o [\1 Fd vl '� I ,I <br /> I`1 1 1 { ...,1 I I'i I - .' .. � I�,.r I. I f.r,�+.II•� .� f '.,' n I...«-/I �: :: � I i'r. I Ire b i.«lel Int r'rvl IIH11 t)"J rl/ :r 1M.1 MI Pnr,at R-ffYJIRCn.9 <br /> Drivers Name(print) Driver's Signature Date <br /> .. -- Pick U Delivery t <br /> Up Z <br /> 4736349 � � S <br /> Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix ❑❑ as '., as <br /> DATE <br /> ❑ 0 " • "110 ❑ a❑ . <br /> @ a ❑ Whole Tire Count ❑ Weight In 9-bs. <br /> ;o ~ ❑ Volume Cubic Yds. Weight in Tons <br /> r' 211 <br /> 650 PU �- e <br /> o G � <br /> fioc� CA qS 1 <br /> ® to/cats <br /> EDER) n,7�, H <br /> I�///��� ^� <br /> (NIA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> 2 V(,9 v 3 9 -070D <br /> 0 /D� Vlhnle Tires) INFO M THE STATE OF CALIFORNIA THAT THE <br /> _I t/ INFORMATION PROVIDED A60VE IS TRUE ANO CORRECT <br /> • • - - • • . a - • • • •n Facility Tire Program <br /> 7V7' <br /> 4736349 -- ❑ Pick Up Delivery ❑ ❑ ® o a a a-o 0 <br /> a DATE []C) ci ❑a Facility Telephone Number � <br /> U �❑ <br /> (D Hauler Tire Program ID / Site Suffix � <br /> MIME <br /> - � � 7 ❑ ❑❑ <br /> E ul ❑ Whole Tire Count ❑ Weight In Lbs. <br /> /11 (�,i 1 �� s Q ❑ Volume Cubic Yds. Is <br /> Weightin Tons <br /> E _ 2-0 <br /> V Q <br /> t <br /> )N/A for I CERHFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Z /} �`\ Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> 31 (� l �J INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. I <br /> • I <br /> ®- Pick Up Delivery ` _I 2 5 ©- d a . <br /> i 4736 ` 49 AEN ❑ ❑ ❑ ❑ ❑ ❑ 1 <br /> a <br /> U Facility Telephone Number <br /> Z DATE ❑) �� ° ]H N <br /> Hauler Tire Program ID / Site Suffix ❑ ❑ <br /> W �❑ Whole Tire Count ❑ Weight In Lbs. <br /> M <br /> i Potttri- �d <br /> Volume Cubic Yds. Weight in Tons <br /> ' D Q 3191719 19I <br /> 51-y-111DI\ <br /> w � j f� 4' <br /> 0Q r1,rl ff �' lll :S HLIi4?r' Initials <br /> f^n'I talf�r di"'P'f]ilr7 <br /> IV iralA ler CERTIFY THAT UNDER PENALTY OF PERJURY OF:E <br /> HE <br /> Z o 9 - <br /> 2 - <br /> �-7/�j/ ' Whole Tires) INFORMATION PROVI EO ABOVE IS'TRUE ANO CORRECT, <br />