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Dept.of Resources Recycling and Recovery <br /> CA Comprehensive Trip Log and Receipts 10002 P.0,Box 1259,Sacramento,CA 05012-1259 <br /> CRycle � XAMP Ez2 Comprehensive Tri .Number <br /> e <br /> 0,8q071 <br /> � <br /> 3rcooa°°irm(nio/INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATEr" <br /> Uy sipnlnp thle CA Compnhenslve Trip Lop and Receipt,the slgnerjal request that the Infc—tion pro dded on 01.loan will be considered confidential,proprietary and tried.eecreL In accordance,with TINS,14 CCR,9ec11on <br /> 17041 et seq.,If is r quest Is made for disclosure of this Information,CalR.oycle will contact the algin. 1)of this form at the address and telephone number provided on this form or recelpt. <br /> a � wehleleunsormat,onr� �� Hauler Address <br /> Truck Decal Number <br /> Business Name Wingfoot Commercial Tirc <br /> RE R °® .® © Address <br /> City,State and Zip 1000 S. 21st Street <br /> License Plate Number State {{ Fort Smith AR 7e� <br /> Common <br /> rieron <br /> Cal� 8Q1 <br /> I certify railer penally of palury under the laws of the Slate of Cahfonila that the Information pmvklad above is true and correct.In addition.I am aware that falslOcation of this informatlon may result In suspension,revocation,or denial of renewal of <br /> the Waste The Hauler Registration pursuant to Public Resources Code section 42,960 and may result In civil penshie,up to$25,o0O per day,per violation or administrative psael up to$5.1100 per vblalion per day as described In Public R,eesiai ces <br /> code section 42902 l <br /> Driver's Name rim Driver's S"M Date <br /> r•; <br /> -nber Load Information Facility Tire Program ID Site Suffix <br /> Comprehensive Trip Log Nui <br /> 4888712 -- C :Pick U Delivery; E0 ,110-0 <br /> n p: 0 11 <br /> �' <br /> Hauler Tire Program ID / Site Suffix DATEFacility Telephone Number <br /> era <br /> Do' 00 <br /> 000- 0000000 <br /> G VC) 1 w 0 Whole. Tire Count 0 Weight in Lbs. <br /> R I a" Facility Business <br /> al I 0 Volume Cubic Yds. Weight In Tons Name/Ad res <br /> E Hauler Name City,Staten Z pID <br /> Stamp or Label OK <br /> t� <br /> Address Same as Hauler <br /> Hauler Telephone Number ■ tr 1 <br /> (N/A IOr I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE 19 TRUE AHO CORRECT. <br /> Facility Tire Program ID Site Suffix <br /> Comprehensive Trip Log Number Load Information <br /> a4888712 -- B . Pick,Up "Delivery <br /> .a <br /> � <br /> Hauler Tire Program ID / Site Suffix n -Facility Telephone Number(DATE' <br /> � a DODO ® � 0 <br /> a.®'Whole Tire Count 0 Weight in Lbs. Facilit <br /> - �wingfoot Commerclal Tire <br /> 1_ l ��` �. �; Volume Cubic Yds. Weight in Tons Name/ d4! ":r� , y r . <br /> N 4 • �l e 'A111cox rod <br /> city,ssttick`�ori`C A 95215 <br /> Hauler Name <br /> Stamp or Label OK -t i <br /> Q <br /> Hauler Telephone Number ■ Address Same as Hauler 1 ,g <br /> /1 (NIA for 1 CERTIFY THAT UNDER PENALTY OF PERJURY of THE <br /> Whole Tiros) LANG OF THE STATEOF CALIFORNIA THAT TIIE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> ' yfComprehensive Trip LogNumber LoadInformationProgram <br /> U <br /> 4 8 8 8 712 " A )Pick U`p Delivery. © [J-pllf ' <br /> ) Hauler Tire Program ID / Site Suffix DATE :� t Facility Telephone Number <br /> N �® 00.tz 0� <br /> gF - imal <br /> C w B{M (LWhoie Tire Count. 0 Weight in Lbs. /� } <br /> ` Volume Cubic Yds. Weight in Tons Nat et/ ilk <br /> E C•• ,, .a(jrl��!��f e(q T exz <br /> Hauler Name �+y, <br /> ��I �.1 U1�oDTDODD Starr c4`t~1b�1K �� 9r"l/ <br /> ■ F1 Address Same as Hauler <br /> Hauler Telephone Numb r� . lri�� <br /> 9-0 q .931 't {NIA for t CERTIFY THAT UNDER PENALTY PERJURYTHE <br /> [ytl <br /> Whole Tires)� LAWS THE STATE OF CALIFORNIAITHAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />