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Ile <br /> Will <br /> Toll Free 1-866' www 96-0600 / calrecycie ca ctov/Tires/ <br /> Dept.of Resources Recycling and Recovery <br /> 10002 P.O.Box 1259,Sacramento,CA 95812-1259 <br /> o2 CA Comprehensive Trip Log and Receipts Com rehensive Tri Number <br /> CalRecyde E X A M P L E 1 2 3 <br /> -� 524264 <br /> Stale ct Cafilorrvafarm yrt I bect,nsd"de <br /> secret.In accordance wnh"'e,td-- <br /> INSTRUCTIONS <br /> ,Section <br /> ala a nno,INSTRUCTIONSnONeBACKeOF PART einfaDOnNOT TAPE STAPLE OR DUPLICATE <br /> II contact the signerls)of this foProvided on th isrm at the address and telephone number provided on this form or receipt. <br /> BY s 9 l 9 this CA ComprehensiveTrip Lea <br /> LTgq,at q If a req est ade for disci sure of this Infoml Lo C IR C <br /> _ e u � � oieltrtisrPf�atia" Hauler Address I Wholesale Equipment of Fresno <br /> Truck Decal Number BLISiness Name dba Wholesale Industrial Parts <br /> Address <br /> R E [L/1 0 E E City,sfi�te and yip 536 Display Way <br /> LicensE Plate Number State�+ Sacramento, CA 95833 <br /> - Golrlmun j <br /> —I <br /> 1-2 <br /> cer�ry under enalty et Perjury under tFe laws of the State of Cafforma that the,nlormation provided aoove is true and cored In 0 M da I am aware that falsification of this information may result n suspenp r rev <br /> as d bn,a denial of renews!0 <br /> the Waste Tim"Hauler Registration pursuarrt to Public Resource f de sectwn 47960 and may resuI In civil pensN!es up to S 26.(!00 per day,per violation or administ 've penanles up to$5,000 per solation per day as cribed In Public Resourt <br /> Code section x2962 / <br /> 1/✓��1t2 ate <br /> Driver' Signature <br /> Driver's Name(pri <br /> .. <br /> Pick Up ❑ <br /> Y 5224264 -- C Delivery:❑ ❑ <br /> •��_ HaFacility Telephone Number <br /> er <br /> uler Tire Program ID Site Suffix DATE [][] <br /> ❑ ❑ ❑ � <br /> ❑ ❑❑ <br /> c a �Whote Tire Gount , Weightinlbs -. <br /> CIS > <br /> ~ Volume Cubic Yds. ❑Weight in:Tons <br /> E <br /> o F <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 IS TRUE AND CORRECT. <br /> I M MUM CM • <br /> Pick Up Delivery f ❑ — <br /> .- 4264 -- � ❑_ ❑ ❑❑ ❑ ❑ <br /> 522 ❑ . <br /> Facility Telephone Number <br /> a) Hauler Tire Program ID / Site Suffix DATE <br /> t= LU Whole Tire Count ❑Weight In Lhs _ v.T <br /> / Volume Cubic Yds. -T— <br /> Weight in Tons <br /> Q i v 7 3 3 — 5e <br /> E Hauler Nan <br /> Q <br /> / - C . .t:. ! .. Initials <br /> r c a _ <br /> r!alAiler Te - (N/A for I CERTIFY THAT UNDER PENALLY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> •.•1M • • <br /> 4 2 6 4 -- A Pickup delivery ❑ ❑ ❑ L❑ ❑ ❑r <br /> Q 522 ❑ ❑ <br /> m <br /> Ell] <br /> Facility Telephone Number <br /> Hauler Tire Program ID / Site SuffixDATE 1111 ❑L <br /> U) <br /> a ❑Whole Tire Count Wel t In Lbs <br /> F- El <br /> Volume Cubic Yds. Weight in.:, <br /> oil <br /> p <br /> 7 <br /> ousoI. ,Address S;3me 8S H .(,Sicr Initials <br /> j --' - I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> riaLller le..t.}J''if.,si r_:.,,_ :; -- _ (N/A for E <br />