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TOIL Free -066-696,0600 / www•calrecycle.ca•gov/Tires/ <br /> Dept.of Resources Recycling and Recovery <br /> CA Comprehensive Trip Log and Receipts 90002 P.O.Boz 1259,Sacramento,CA 95612-1259 <br /> Comprehensive Tri Number <br /> CalRecycle EXAMPLE 123 � . . ' �- �+ ,, I <br /> CelRayReGve�(7110)INSTRUCTIONS ON RACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE :U -�® - <br /> By signing this CA Comprehensive Trip Log and Receipt,the signers)request that the information provided on this form will be considered confidential,proprietary and trade secrcl.In accordance with Title,14 CCR,Section <br /> 17041 at seq.,If a request is made for disclosure of this infomration.CalRecycle vril�ontact the signer(s)of this form at the address and telephone number provided on this form or receipt. <br /> "�r•'�.- �`lietiic`I011Hf,3YtY�at[on� _ s- --- — <br /> ✓ftler Address i <br /> ITri-Ick <br /> �ec_!, ,ber ttsit,ess N�rt,e Wh0lesale Equipment of Fresno <br /> nq <br /> ® LJ Addiress dba Wholesale industrial Farts <br /> t�sLr, <br /> State and Zit �@ <br /> License Plat=`I uer State 536 Display Way <br /> flc <br /> 3c m,�t,l, , Sacramento, CA 95838 <br /> L_J �—� Carrier (-- -- <br /> certify under penalty of pariury under the laws of the State of California that:he information provided above is true and correct.In addition,I am aware that falsification of this information may result In suspension,revocation,or denial of renewal of <br /> the Waste T.Hauler Regislratien p uanI to Public Resources Code section 42960 and may result In civil penalties up to S 25,000 per day,par violation or administrative penaltl s up to 55,000 per violation per day as described In <br /> Public Resources <br /> Code section 42962 r �_. <br /> Y <br /> _ Driver's Name nt) Driver's gn tore Date <br /> er ..• . . .. Site Suffix <br /> ram ID <br /> ,J <br /> 748 618 01 Pick Up � Delivery <br /> 0 <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> X31'-1Tc -- <br /> in <br /> Whole Tire Count Welcrlt in Leis: i <br /> ® I Volume Cts�,ic Ycis. Weight in ions _. <br /> E Hauler Name <br /> V it < <br /> H 't:la(-Tg1�1�t-IOf :, fj'.C�CireSS SEP e as Hauler initials ... <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> VA-le Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMA ION PROVIDED ABOVE IS TRUE AND CORRECT <br /> 4861801 Up Deliver �,. `7 c' C�� E- <br /> E- <br /> Z <br /> 0 Hauler Tire Program ID / Site Suffix ] Facility Telephone Number <br /> DATE <br /> Z H /ILX <br /> �a <br /> LU <br /> lyWhole Tire Count Weighs:in Lbs. <br /> 1 3131 () / Volume Cubic Yds. Weight in Tons S 314, 2), A. ;r �✓c� <br /> o Hauler Nam j <br /> I <br /> Hauler TeleDhor;e It,wiiber �+ I u 1 Address Sante as Hauie` <br /> Initials <br /> (N/A.iar I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Wii7ale-drys) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> �C)--� <br /> J V INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> 4861801 �� � <br /> �= DP-il-k UR i�eiiveryr <br /> �y Hauler Tire Program !D / Site Suffix Facility Telephone Number <br /> DATE <br /> B.. <a 0-Whole Tire Countbs, � Weight in L <br /> o 0 0 a o 0 0 o a a <br /> ci Hauler Name.r <br /> ® ~ Volume Cubic Yds. VJeight in Tons ff <br /> E. <br /> Ha Vic. .o tt w �a; ew s- t �'� c_ r (.;v..r -- <br /> - Initials <br /> -- - - fN/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE 7 <br />