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T®II Free 1-866-896-0600 / www.calrecycle.,. .qov/Tires/ <br /> Dept of Resources Recycling and Recovery <br /> F <br /> a CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 <br /> Comprehensive Tri Number <br /> Recycle ❑ P E i z 3 K DUPLICATE 8 6 810 <br /> � ° 'a INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE ORe 2R3 p/10) <br /> By signing this CA Comprehensive Trip Log and Receipt,the signer(s)request that the information provided on this form will be considered confidential,proprietary and trade secret. In accordance with Title,14 CCR,Section <br /> 17041 el seq.,If a request is made for disclosure of this Information,CalRecycle will contact the saner(s)of this torm at the address and telephone number provided on this form or receipt. <br /> J <br /> fi elnformafion' ' Hauler 7Ns1d('e4s FWholesale <br /> Truck Decal Number Business Nanta holesale Equipment of Fresno <br /> :address dba Wholesale Industrial Parts <br /> ❑ ❑ G' Cl A Stag arta zip 536 Display Way <br /> License Plate Number State <br /> �7 ❑{ U ❑ ❑ Common Sacramento, Cit 95636 <br /> A <br /> ❑. 7❑ ❑❑ ❑ Carrier <br /> I certify under penalty of peoury under the haws of the-State of California that the information provided above Is true and whilct.In addition,I am aware tthorf falsification <br /> o this information <br /> nti r uP to may re per sult In suson per day as aeon,or denial ofrenewal <br /> nesol of <br /> rtes <br /> the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result In civil penalties up to S 25,000 per day,Pa n u <br /> Code section 42962 <br /> «► d✓i� <br /> Driver's Name(print) Driver's Si ature a <br /> te <br /> � � s1810 �� � Pick Up Delivery _❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑❑ ❑❑ <br /> ❑❑ Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix DATE / ❑ ❑ ❑ ❑ ❑ <br /> W ❑Whole Tire Count Weight in Lbs. <br /> m _._ <br /> ❑Volume Cubic Yds. Weight in Tons <br /> W i <br /> E Hauler Na3n- <br /> in <br /> U ® ❑ Address zee as Hauler Initials - <br /> Hauler Telephone NIM-lb til (NIA 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 /> 74- 48161810 OURPick Up � Delivery❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix DATE no PS <br /> ` y <br /> W Whole Tire Count El Weight In Lbs. <br /> ❑Volume Cubic Yds. ❑ Weight in Torts <br /> 101 / <br /> E Hauler E m C'.� X 3 5 <br /> C) �� '._.J Arliii'e-SS same as Halder Initials <br /> WlaulerTeleNhoneNurnber Y i (WA for ICERnFYTHAT UNDER PENALTY OFPERJURY OFTHE <br /> Whale' es) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> (J r t1 INFORMATON PROVIDED ABOVE IS TRUE AND CORRECT <br /> 4861810 a® � ❑Pick Up _❑ Det fiery 1 00000 ❑ <br /> Facility Telephone Number <br /> d= Hauler Tire Program ID / Site Suffix , <br /> DATA <br /> Duo <br /> ❑❑� ` ❑ ❑❑ <br /> s=. w ❑ Whole Tire Count .❑,Weight in Lbs. <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> R s. as <br /> Volume Cubic.Yds. ❑Weight in Tons - <br /> Hauler Na'ri-ie -x <br /> rn F•""` <br /> el':-t,ltt-.f3.. ?:.,.iia_ i—,} li.t.,Cr eSS.C.;..r _ asi-4ulli("• initials <br /> - 1N/A for -.- I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE , <br />