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lreS/ <br /> '6` calrecVcie.-.,..gov/Tires/ <br /> ® 1-866-896-06 <br /> 00 / www ��,� <br /> T®� ��6� 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 irehhenSive Trip Number <br /> cIe ExA ►� P E 1 �; 4861834 <br /> 6alReCy PART 2 DO NOT TAPE STAPLE OR DUPLICATE 14 CCR, <br /> INSTRUCTIONS ON BACK OF onfidentiat,propnetary and trade secret In at. dance <br /> Sale of Ge�lom,a provided on this form or receipt. <br /> CaWecyrJe 203(1!101 d 1111110 the s gne ls)r qu ri that the information provided th this <br /> at theladdress rand telephone number pravi <br /> ey signing this CAC mp h ve T p L 9 anle w II oorts:t the sgnerfsf o <br /> 17041 et seq.,if arequast mad fo d closu sure <br /> his Info t nCaIR y i_ �olesale Equipment o7Parts <br /> ,��t Ivx -, .dfeTticle.inforinatfon. Hauler Andress ! i fFresno <br /> Truck Decal Number J Business Narme dba Wholesale Industrilp a9 Address 636 Display ',/JaLiLyt S ate and dipSlate $�mr�rrtento, C, 95 <br /> License Plate Num <br /> ` `sm 11cri i <br /> a �-,arrlt r <br /> 42rm sna may result in civil penalties up to 5 25,000 per day.Dar vlolatlw or admimstoRiv enalbes up to$5.000 per violation per day as describ m Public Pesourres <br /> 1 Cedlfy under penally o1 perjury <br /> under the laws of ina State of Galiio�nla that the Information prov7tled above is true and coned.In addition,I am aware that falsification of Ihrs information may result in Suspension,revocation.or denial cf�e�al o <br /> the Waste The Hauler Registration pursuant to Public Resourczs Gone S^fon <br /> Code secfl-429621 j{t ate <br /> it Driver's f a ur_e <br /> Driver's Name kt <br /> rint � , e - <br /> �® Pick UP Delivery a <br /> DE <br /> �- /n� 8 c 8 3 4 ❑ Number :L <br /> a t J 6 8 Facility Telephone <br /> m <br /> oilHauler Tire Program ID / SiteSuffix BATE . oao <br /> Whole Tire Count El <br /> Weight In Lbs. <br /> •E <br /> ® I volume Cubic Yds. ❑Weight in Tons <br /> w I <br /> oavi r«ame <br /> a e A-ddress Sarne as InitiafS <br /> (NIA far l CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> SYh01e Tiresi <br /> L(FORMATION PROVIDED ABOVE <br /> 3T <br /> AND CORRECT. <br /> Pick Urn Delivery L1 i 2 <br /> 4861834 <br /> Number <br /> a Facility Telephone <br /> 0 Hauler Tire Program ID / Site Suffix DATE 73 IaC I ' / �lT ► ) / <br /> l��J �JL <br /> 451 1 <br /> aa� o <br /> wr3 Whole Tire Count ❑Weight to Lbs <br /> �]E]Volume Cubic Yds. Weight in Tons L 4} `-`• �.�^�y <br /> m S <br /> -,;74 Ono9E �� Y.C'1`. rc .a:.lt it L-�c7 qiie: Initial <br /> U f <br /> N/A for I CER00 <br /> TIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> 1�.-f }!?t ...... ..... .. r LAWS OF THE STATE OF CAUFORNIA THAT THE _ <br /> ,. <br /> — - Pi'hofe.fres) <br /> {NFOR77�AT70N PROVIDED ABOVE IS TRUE AND CORRECT. <br /> R AND CORRECT. <br /> • . - - - . • . . - • ... • • • • 1 <br /> 4861834 -� Pick ®ells `' <br /> £� Hauler Tire Program ID / Site Suffix , <br /> Facility Telephone Number <br /> l DATE <br /> LLL _ - 000== oa0000a <br /> rt ul Whole Tire Count F1Weightin Lbs: <br /> v <br /> FT <br /> volume Cubic Yds. E] Weight in Tons <br /> Hauler Name <br /> Ado <br /> j� � .tea.�a112cZu l <br /> t� 1 I ni(ials <br />