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"Dell Free 166-696-0601/www.calrec cic- -d.gov/Tires/ <br /> Dept.of Resources Recycling and Recovery <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 <br /> Comprehensive Trip Number <br /> calRecycle EXAMPLE 1 2 3 - - 224.287 <br /> Stale fCalilon' S <br /> ,,,, =(711,j INSTRUCTIONS ON BACK OF PART 2 O {OT TAPE.STAPLE OR DUPLICATE _ <br /> By signing tins CA Comprehensive Trip Log and Receipt,the signers)request that the infonnation'�priavided on this f6 m will be considered confidential,proprietary and trade sc cret In accordance with Title.14 CCR,Section <br /> 17041 ct seq.,If a request is made for disclosure of this information,CalRecycle will contact the slgner(s)of this Torn at the address and telephone number provided on this form or receipt. <br /> Whii;le inf6ftatiorr <br /> Hauler Addr vws �. ._. <br /> Truck ocuat lei rT h ,. <br /> St;�ir,EiS�d�rf1C Wholesale Equipment of Fresno <br /> (� (� Address <br /> Addr`�ssdba Wholesale industrial Parts <br /> Lfcer'se Plate(!umber State_. <br /> City:State and zits 536 Display Way <br /> C`"' "'r` E__ Sacramerita, CA 95838 --- <br /> Carrier <br /> I certify under penalty of perjury under the laws of the State of California that the information provided above is true and Correct.In a;dItion,I am aware that faistfication of this information may result in suspension,revocation,or denial of renewal of <br /> W <br /> the aste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to S 25.000 per day.per violation or administrative penalties up to 85,000 per violation per day as described in Public Resources <br /> Code sect2962 <br /> Driver's NaMp (print) Driver's Signature Date <br /> loombr6hensive TriiKill:ll:. • - ei• information'. • • - <br /> 5224287 2 4 2 8 7 ��' F1, Pick Un Delivery <br /> T g / -� Facility Telephone Number <br /> Hauler ire Program ID / Site Suffix <br /> DATE <br /> 00o PLl <br /> LU Whole Tire COl Q,Weighti.Lb., <br /> l- <br /> m •� ~ Volume Cubic.Yds. 0,Weight in Torts <br /> E Hauler r!?tl LO <br /> Q ; i /r6ELfiter "„ _ <br /> EEDnEiVIE, ;---A ._ Initials ... <br /> - f Iv%F for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE 15 TRUE AND CORRECT. <br /> ID <br /> Q 5 4 2 8 ®� ❑ Pickp leGi�fel ® 0 a a s <br /> U <br /> Facility Telephone Number <br /> 0 Hauler Tire Program ID / Site Suffix DATE <br /> IV, . _ oo � � 000aoo <br /> ta a - <br /> V�hDle The Count Q VJelght In Lb <br /> f Volume Cubic Yds. (;v. 1� <br /> Weigh�ifs Toni <br /> - <br /> O hauler <br /> El E <br /> r; Via,;:.; E ri�.fCt�i i i �' _ Initials <br /> r - (14! <br />