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l Dopt.of Resources Recycling and Recovery CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 comprehensive Tri Number CalRecyde x A M P E {2 N L. smf.afc.ea w. O INSTRUCTIONS ON BACK OF PART 2 DO NT TAPE STAPLE OR DUPLICATE C fflecxle M f7nf1) By alening thle CA Gomp,.henelve Rip Log end Receipt,the nignor;*)requent that the Informnllon provided on ih1.la rm will be con.1d.red conlldential,proprietary and trod.aacnl,In accordance with Title,14 CCR,Section 17041 et eeq.,N a request Ie made for dlecloeun al Chia Inlorm.tl.n,C.IRecycle Wil contact the eigner(e)of[file form et the addreee and leiephoae number provided on[file loan or receipt. Vehicle Information Hauler Address Truck Decal Number Business Name ❑ ❑ -� ❑ a ❑ ® ® Address Wingfoot Commercial Tire City,State and Zip 1 000 S. 21 St Street Licens late Number State a E Ra a ® ❑ ® common Fort Smith AR 72901 Carrier I catity under penalty of perjury under IM lawn of the Stele of Cahlanlo that it a infomwlioa provided nb.-Is trua and car.ct.In addition,I an awara 11.1 talellkat-of this intormatlon—y—ult in suspenai..,re—M...or dental of renewal of the Wost.Tire Houle,Flog.1rat—Du ant to public Resoumm Cade-ton 42960 and may result In trail pernalt—up to$25,ODD per day,pw violation or administrative penis up to S5.D0e per violation per day as d—abed in Public Rasourcea Cade sectlon 42962 6 F�U1 a -1 -( l' V l Driver's Name'print' Driver's Si natu a Date Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 4 88 8705 " C Pick Up [],Delivery_0000_000 AL Hauler Tire Program ID / Site Suffix DATE 00 Facility Telephone Number V { IC) 1 ❑ Whole Tire Count ❑ Weight in Lbs. 1 // Facility Business ,,,� ❑Volume Cubic Yds. ❑ Weight in Tons Name/Add,`�'s.�/ l E Hauler Name City,State a'S ' ip 1 UQ Stamp or Label OK Hauler Telephone Number EDDOOMED ❑ Address Same as Hauler mill rs —J {N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROYIbEb AEOVE 19 TRUEAND CORRECT, aao Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix errs -7 g 4 8 (�J �— p Pick Up Delivery r ,� © ®-❑ a w n Facility Telephone Number Hauler Tire Program ID / Site Suffix DATE / ❑❑ / 0 o ❑ � r- ©❑ ❑ aaa ® c w 19 Whole Tire Count ❑ Weight in Lbs. 1 CL Facility Bu;1�F tCC� i_C r' ^s � Volume Cubic Yds. y ❑ Wei ht in Tons Name/Ad StD . �11C) Tire City,State t.a'ktCfJ C.A(\r`r c; Hauler Name 9•521s Stamp or Label OK a ■ 1 ❑ Address Same as Hauler n fiars Hauler Telephone Number 7r�-.Y'Y/� Whole TI r I C y FY THAT UNDERr CALIFORNIA THAT THE F THE 1 '5 r V r�v c� 2 Wh010 T r09) AWS OF THE STATE OF CALIFORNIA THAT THE �,I �T INFORMATION PROYIDEO Aa0VF IS TRUE ANO CORRECT Comprehensive Trip Log Number Load Information Facility Tire rogram ID Site Suffix x4888705 -- A Pick Up Delivery o WHauler Tire.Program ID / Site Suffix ❑o DATE Facility Telephone Number❑o ❑ - b , to a ®.Whole Tire Count ❑ Weight in Lbs. �1 // F� Et.A3 4L A o �� 3 S E]Volume Cubic Yds. ❑ Weight in Tons NP.9, t•ul►idr© Hauler Name City,!��iat' e and U �Utl-rcio � EwE- E Stamp or Label Oi'a J Hauler Telephone Nu r Address Same as Hauler Initials { for 1 CERTIFY THAT UNDER PENALTY PERJURYTHE Whoolele Tires) LAWS OF THE STATE OF CALIFORNIAI THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. �'''