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Clept.of Resources Recycling and Recovery <br /> Ila CA Comprehensive Trip Log and Receipts 10002 R0.Box 1259,Sacramento,CA 95812-1258 <br /> Comprehensive Trip Number <br /> Cdecycie E x A nn P L E12 3 4 8.88 73.9 <br /> ca ,*OfceT`M,,- <br /> yaeaDnn,INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE ' j <br /> By III ninq Nis CA Comprehomslre Wp Log and Reoelpt,the signerls)request that the information provided on this forth vrlll be"nsicloned confidential,proprietary and trade secrel.In accordance with Title,14 CCR,Sectlon <br /> 17041 of sec,,N e request ta mad•for disclofum of this inlortnab..,CelRecyela will contact the signarls)of title form at dw addreas and telephone number provided on this torn or nceApt. <br /> pt r Vehicle Information' , Wih foot Commercial i <br /> Truck betel Number � Hauler Address � Wing <br /> foot <br /> Name 1000 S.21 st Street <br /> IN — no ERR © Address Fort Smith AR 72901 <br /> City,State and Zip <br /> License Plate Number State <br /> a © � E ERR © ® I Co <br /> Carrieron I <br /> I cmtlry under penalty of penury under the Iowa of the Slate of Cell'ornlat that the Information provided above la true and carr L Innddillill.n,I am.were that telelllcallon of thle Informatlon may result In susponadr,revocation,or denial of runewal of <br /> the Wosto Tiro Hoular Registration pursuant to Public Reaaurces Code eactlon 42900 and may mauft In Clvll pen.ltles up to 525,1X10 per day,per vloWlon or edImI.Islralive Penaltlea up to$s,OD0 per vlolatlan par day ae described In Putalc Resources <br /> Coda a.Ctlon 42802 <br /> Driver's Name rint A Driver's Sin ture Date <br /> Facility Tire Program ID Site Suffix <br /> 4 8 8 8 719 " C Pick Up.' Delivery a-D <br /> a oaaooa <br /> Hauler Tire Program ID / Site Suffix DATE a <br /> Facility Telephone Number <br /> oo , 00 � a <br /> 1 -- oao- aoa0000 <br /> a / wa ❑Whole Tire Count Weight In Lbs. <br /> /// Facility Bu. iness <br /> [IVolume Cubic Yds. E]Weight in Tons Na /Ad re <br /> M_ Hauler Name City,S 3 clip <br /> UStamp or Label OK <br /> Hauler Telephone Number ■ ❑ Address Same as Hauler Dm+ <br /> (N/A for 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 AND CORRECT, <br /> n Facility Tire Program ID Site Suffix <br /> ,. 4 8 8 8 719 -- B Pick Up Delivery <br /> a ao �000a <br /> v Facility Telephone Number <br /> a Hauler Tire Program ID / Site Suffix DATE <br /> c tu'® Whole Tire CountWeight in Lbs. <br /> Facility Business <br /> •I I .,. ar Volume Cubic Yds.flWeight in Tons Name/Address <br /> City,st�Wingfoot,COM mercial Tire <br /> o Haul Name. . 4045 N Micox ltd <br /> Stamp St0cktbill`CA 95215 <br /> Hauler-Telephone Numbipir E DORE 'ODE' <br /> ❑ Address Same as Hauler <br /> • ar�, /'-y (NIA for I CERTIFY THAT UNDER PENALTY OF PERJURYOFTHE <br /> �' (-'!r) Whola Tires) LAWS OFORF THE STATE OF CALIFORNIA THAT TNQ <br /> .. V -3 44 INMATION PROVIDED ABOVE IS TRUE AND CORRECT. . <br /> Comprehensive Trip • Number • • InformationProgram ID Site Suff ix <br /> Q <br /> 4888719 " A T <br /> Pick Up DeliveryG 10 ® PIN ® H- L 4 <br /> lu Hauler Tire Program ID / Site Suffix nn DATE Facility Telephone Number <br /> ® � ®U / �© <br /> ro ® Whole The Count Weight In Lbs. Fr tIJtess�` y-} 4 <br /> a ' ' Volume Cubic Yds. Weight In Tons Na ne/A 4,ss <br /> o Hauler ams G to , IC <br /> cv <br /> Hauler Telephone Numb 500DROPE Address Same as Hat,ler Initials <br /> 1 (N(A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE ,•+'" <br /> /\ ( Whole Tire a) LAWS OF THE STATE OF CALIFORNIA THAT THElr� yJ� <br /> LJ i INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. 1r ' <br />