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' Dept.of Resources Recycling and Recovery <br /> CA Comprehensive Trip Log and Receipts 10002 D.Box 1259,Sacramento,CA 95812-1 259 <br /> C rehensive Tri Number <br /> CalRecyCle x A nn p E z 3 �. <br /> SLM1 W CarfmW. 4 6 8 3 6t' <br /> INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR'DUPLICATE <br /> By efgning thla CA Comprehens"THp Log and Receipt.the slgner(al req--Shat the Information Provided on thio form Wil be conaldered confldentlal,proprietary and trade secret. In accordance with Tidaq 11 CCR,Bection . <br /> 17041 st seq,If a request Is made for dlaclosuro o1 this Information,CnIROCyele will contact the■Jgner(,)01 this form at the address and telephone number provided on this form or receipt. <br /> Vehicle Information Hauler Address <br /> Truck Decal Number Business Name <br /> Address Wingto0t Commercial Tire <br /> City, State and Zip 1000 S.21St Street <br /> License Plate Number Stat© <br /> ® ® ® ® ® U ® ® ❑ Common, Fort Smith AR 72901 4 <br /> 1 certlty under penalty of penury under the laws o1 the State of Ca lfornla that the fnformi llon provided above fs true and correct.In addition,I am aware that falafficatlon of this Information may msull In auspenslon,revocation,or dental of renewal of+•. <br /> the Waale Tire Hauler Registration pursuant to Public Resources Coda soollon 429N snip may fasult in civil penaNies up to$25,000 par day,M vioiatlon w odminb Uva penalties up to 55,000 per violation per day as described In Public Reaaurcee <br /> Code sectbn 42982 <br /> L� o1� <br /> Driver's Name rint Driver's Si natu Tire Program ID Site Suffix <br /> Date <br /> C ompr hensive Trip Log Number Load Information <br /> Or <br /> ' 48 88 60 3 �- (; Pick up. Delivery <br /> U <br /> a as <br /> Hauler Tire Program ID / -SIte.Suffix DATE f Facility Telephone Number <br /> as oa oa <br /> . aoo-ooaooao <br /> Lu [I Whole Tire Count Weight In Lbs. <br /> D Facility Business <br /> E] Volume Cubic Yds. Weight in Tons iVamelAdd'oss <br /> E Hauler Name <br /> City, <br /> State red i 1`{ <br /> 3 Stamp or Lab I OK LL <br /> U <br /> Hauler Telephone Number ■ Address Same as Hauler ,rpr3 <br /> (NIA for I CERTIFY THAT UNDER PENALTYOF PERJURY OF THE <br /> t Whole Tires) UrWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT <br /> a- <br /> Comprehensive Trip Log Number Load Information Facility Tire <br /> �a- Delivery aal Program©4888603 --.8 Pick Up <br /> I <br /> a <br /> 0n Facility Telephone Number <br /> Hauler Tire Program ID'/ Site Suffix DATE <br /> c � w Whole Tire Count Weight in Lbs. <br /> CL - Facility Business <br /> r` Volume Cubic Yds. Weight in Tons Name/Ad-il OOt COMMercial Time ' <br /> Ha ler Name City,Stat404,52P ;Nilcox rod <br /> E `Stocktori'CA. 95215 . <br /> Stamp or Label OK <br /> Hauler Telephone Number _ , ■ Address Same as Hauler- •- --Initials "1 <br /> r� t- (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> 'J`.t�� s-j'�" Whole Tires). LAM OF THE STATE OF CALIFORNIA THATTHE <br /> (�_0 �% 'INFORMATION PROVIDED ABOVE IS TRUE AN CORRECT, <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suff ix <br /> 4-888603 A Pick Up Delivery -.Q� <br /> LU <br /> is Hauler Tire Program ID / Site Suffix DATE Facility Telephone Number <br /> D U <br /> ro LU D,Whole Tire Count Weight in Lbs. `` <br /> Volume Cubic Yds. ❑ Weight in Tons N melAcl3n Jss f �r�1T "S <br /> o -Hauler Name- .� tec„� +U��J D �p <br /> / ("i �l r� <br /> Hauler Telephone Nurrsrlltl••leer ■ Q Address Same a M11 11.1 rfruafs <br /> - �t (NIA for I CERTIFY THAT UNDER PENALTY NI PERS T T OF 7HE <br /> /L!) `Ttilll Whole Tlroa} LAW9Of THE STATE OF CALIFORNU THAT THE <br /> INFORMATION PROVIDED ABOVE t4 TRUE ANO CORRECT. <br />