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Toll Free 1-866-896-0600 / www.calrecycle.ca.gov/Tires/ <br /> Dept.of Resources Recycling and Recovery <br /> CA Comprehensive Trip Log and Receipts 10002 P.D.Box 1259,Sacramento,CA 95912.1259 <br /> E X 1 2 3 Comprehensive Trig Number <br /> Cal6ecycle A M P L E 1855 <br /> civmeiiiriiiilo)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE <br /> By signing this CA Comprehensive Trip Log and Receipt,the signer(,]request that the information provided on this form will be considered confidential,proprietary and trade secret,In accordance with Titre,14 CCR,Section <br /> 17041 at seq If a request is made for disclosuref this information,CalRecycle will contact the signer(s)of this form at the address and telephone number provided on this form or receipt. <br /> . �1llehctO1tIform6ttan Hauler Address -- . <br /> Truck becal Number II Wholesale Equipment of Fresno <br /> Busn Acld'rless(vamp dba Wholesale Industrial Parts <br /> a a U [IF] [I Ccidreta Ctty,stere an zip 536 Display Way <br /> License Plate Number State <br /> DUD � Ccoarrieron I_ Sacramento, CA 95838 ---- <br /> certify under penalty of pe"under the taws of the State of California that the Information provided above is true and correct.In addition,I am aware that falsification of this information may result m su,pension,revdcation.or denial of renewal of <br /> the Waste Tim Hauler Registration pursuant to Public Resources Code section 42960 and may result in civit penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as deic ibed in Public Resources <br /> Loda section 42962 <br /> Driver's Name(print) Driver's Signature Date <br /> . <br /> 4861855 -- C Delivery <br /> Facility v Hauler Tire o ram ID / Site Suffix Tele hone Number <br /> � ;�g DATE p <br /> aa0000aaoa <br /> fn <br /> w -- <br /> m <br /> } Whole fire CountWeight in Lbs. <br /> V6yme Cubic Yds. <br /> E Weight in Eons $, <br /> x <br /> G Hauler Name <br /> N <br /> Hauler Teiep one Nui r ■ l ;-sf ;4 ;-;:s ,r€te pis l fa�(fer - <br /> L._1 -- lnitiaLs <br /> OE <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tiros) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> g <br /> 4861855 -- ick Up U Delivery _ <br /> ooaoa0000 : <br /> HauterTirerogram ID Site Suffix <br /> P / 1 j Facility Telephone Number <br /> � DATE �� . •� <br /> m • <br /> a Whole Tire Count Weight in Lbs <br /> 000� oaaooL <br /> / (� •� C" i ® Volume Cubic Yds. Weight in Tons `. <br /> c Hauler Name e <br /> Ha- +=+ feel.),} ui'i .�:f;rY- +.3S H3i.lie` Initials <br /> c l_ <br /> ]NIA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE "/J <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT <br /> Comprehensive Trip Log. Number Load Information Facil ity Tire Program 10 -site, giwlx- <br /> 4 8 618 5 5 - A Pick Up Delivery <br /> �~ Facility Telephone Number <br /> Hauler Tire Program IU / Site Suffix BATE [1a 11] [111 <br /> C w El hole Tire Count O Weight In Lbs. _ <br /> ro a. <br /> Volume Cubic Yds. F1 Weight in Tons <br /> o Ha <br /> Y , <br /> in <br /> a c H �. a ■ �� Address ramp an Hauler minais <br /> U I" <br /> -. �..'• 1" _._. .:�i''_X: >.,,, _..-,.__ 'N/A forI CERTIFYTHAT UNDER PENALTYOF PERJURY OFTHE — <br />