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Toll F e 1-b66-896-0600 / www.calrecvcle.ta.gov/Tires/ <br /> Dept.of Resources Recycling and Recovery <br /> oa CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 <br /> EXAMPLE 1 2 3 _ <br /> Comprehensive Tri Number <br /> calRecycle 5224292 <br /> s�lta�.un. <br /> Calaayee2gsp/1g)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE <br /> By signing this CA Comprehensive Trip Log and Receipt,the signerls)request that the information provldad on this form will be considered confidential,proprietary and trade secret In accordance with Title,14 CCR,Section <br /> 17041 et seq.,I1 a request is made for disclosure of this information,CalA.cycle will contact the signer(s)o1 this form at the address and telephone number provided on this form or receipt <br /> mw irCm-nf<fYiPIr1t101� ✓ <br /> Truck Decal NumberHauler Address j <br /> Business Narne Wholesale Equipment of Fresno <br /> F61 � � ��+dress dba Wholesale Industrial Parts <br /> License Plate Number State City;state and dip 536 Display Way <br /> Sacramento, CA 95838 <br /> certify 'ler penalty of perjury under the laws of the State of at forma that'he infdrm tion p,ov ded above is true and coned In addron,I am aware that falseci l on of thisn <br /> mfonat—may'esut In suspension, ewcati.r or den al of renewal of <br /> the Waste Tre Hauler Req strm urs 1 to Pub. R e,00s Ccde sect on 42960 and may lin Ml penalties up to 5 25,000 par tlay per v olat on���orfffadmin t ve ponaltes up to 55.000 per v'olalion per ay as d abed in Publ'c Resourc s <br /> Codes <br /> Driver's Na rint) Driver's i na#ure Date <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suff ix <br /> 5224292 -- C Peek up Delivery ❑ ❑ ❑ ❑_❑ ❑ <br /> v Facility Telephone Number <br /> Hauler Tire Program ID / Site SuffixDATE ❑❑ j ❑❑ �� <br /> wa ❑Whale Tire Count ❑Weight In Lbs. <br /> ffff� 11 l ❑Volume Cubic Yds.❑Weight iri Tons' <br /> E Hauler Namt. <br /> N F- <br /> 3 <br /> Hauser CeiP( f?r3r , ■ j ti r l �,, :11er Initials <br /> (NIA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE=CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> .m <br /> 5224292 -- Peek Up Delivery Ua a o 0 N—U0 ❑ <br /> Facility Telephone Number <br /> rr Hauler Tire Program ID / Site Suffix DATE <br /> e w [Whole Tir aunt []Weight In Lbs. <br /> t O / ffff— E] VolumeCubic Yds. ❑Weight in Toms <br /> E Hauler M',Pnq <br /> i 2ttfe; !.i;_r. ■ A tr ss Sarhe as Hauler Initials <br /> / yS� - (NSA for 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> ` `�5.3� - Whole Tires) LAW. THE STATE OF CALIFORNIA THAT THE <br /> VV INF."fil N PROVIDED ABOVE IS TRUE AND CORRECT. <br /> J,I Comprehensive Trip Log Number <br /> f Load Information, <br /> aF ❑ ❑ ❑ ❑ ❑ ❑ ❑-❑ ❑ <br /> 5224292 -- A 'U Uellve <br /> Hauler Tire Program ID / Site Suffix Facility Telephone Number <br /> ho <br /> f ❑ ❑ ❑ ❑ ❑❑ ❑ ❑ ❑ ❑ <br /> �' '� .Whole Tire Count ulfeigtltvt Lbs <br /> Volunt6.CubrcY4 Wer�hf qn Tone, <br /> { Ir it <br /> Hauler N^r•Ie <br /> �r. H..{I'`r Terl .-- �; .. - �- ii Address Same as lea ,t;-:tInitials ._.... <br /> .yl _ <br /> (CERTI.�...FY THAT UNDER PENALTY OF PERJURY OF THE <br />