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•_go. Dept of Resources Recycling and Recovery, CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95817-1259 Comprehensive Trip'Number. 1- Ca1Recyc1e E X A M P L E 1 2 3 sRp� ,. 1 SG.Y dCe6lane 4 f 8 2 6 9 1 '� 1kDteByde�gthiINSs CA CTRUCTorriprehensivb TMO NS ONand e1BAespt.the ig OF�PARest T eIthe nforDO NOmation T TAon IPE.STAPLE s form �OR DUPUICATEetary and tradesscnt In—order—with Title,14 OCR.Sac! 170/1 at sea.,N e request Is made for disclosure of this Information,CalRecycte will contact the signer(s)of this form at the address er,tl telophons number provided on this form or receipt - '•' Vehicle Informationr Truck Decal Number Hauler Address I��C11%.n — ® © � Business Name ✓ l -+ Address 313V !� W,�S� � "• {N� City, State and Zip License Plate Number State EiCom Carieron L 1 I I canny under penalty of perjury under the laws of the State of California that the information provided above is We and correct.In addition.I am"t t falsification of this i4forma_tion may result in suspension,revocation,or denial at renewal of the Waste Tee Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to E 25.000 per day, 'olaf or administrative penalties S5, i violation per day as described in Public Resources i Cod e s�(e. jprr02B62 1 �7 1`r� 1 <r,r C�1 �� C.Cn\h''� S. .1.1 A.(1,C.��i l•E"� �J L L L.`i.�`t�t.r J�L'�' r. 2 Driver's Name(print) D ' er's Signature Date Comprehensive Trip •. Number Load InformationProgram 4 7 8'2 6 91 C ❑Pick Up Delivery a a a ®❑ © Id c 9 DATE ® / / ❑� Facility Telephone Number. Hauler Tire Program ID -/ .Site Suffix w Weight Ua.o"o .: wCIL ®Whole Tire Count ❑We g b C ` Facility business s, loll Volume Cubic Yds. ❑Weight in Tons Name/Address I c Hauler Name City,State'and Zip . :...� �.� aEDE Stamp or Label.OK - r� U . �, Hauler Telephone Number. ■QO Address Same Hauler Initials �� / I (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE l/lam�� S Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE. yam(+t _ INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. J �••/ Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 4 7 8 2 6 91 -- B Pick Up Delivery Q LA L1o a R w N E H_� o )..:_ 4 UE Facili Tele ,t t . Hauler Tire Program ID / Site Suffix DATE O / N[j / Ty Telephone Number ' aw ®Whole Tire Count Weight m Lbs. i . iii busint,.ss ] F1 Volume Cubic Yds. Weight in Tons t(!�1i�� t,'ess`G nS�U 1 s0 E Hauler Name Q�9p«toy " (( U VQ�JC t\fl()ler '�j�sDEER S mo °nye G S H Tele onp7777 Number k Address Same as Hauler . Initials �1\l1 r�' (\/ �/ (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE ,, I Whole Tires) LAWSOF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number LoadInformation Facility Tire Program ID Site Suffix x k Pick Up. Delivery - ❑ 4 7 8 2 6 91 -- A El U [N ❑ Qu ® * a Facility Telephone Number Hauler Tire Program ID / Site Suffix cc DATE �:./ UH c w ©Whole Tire Count®Weight in Lbs. FF k xi*cj7'��r�jnE .9c o h El Volume Cubic Yds. Weight in Tons K'ame/Addy-ss E Hauler Name ~ ��-''4��S�E� GiL c►5 2b 2 aI Hauler Telephone Number 2 ■ X x ❑ Address Same as Hauler Initials J l' I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE r (N/A for n .• .\Z� ! _O' Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE �Y[ \ IO INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT -