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sources ing 0 CA Comprehensive Trip Log and Receipts ePLox1.29,Sacramento,CA9512-12ry 1 UUI)2' P.O.Box 1259,Sacramento,CA 95812-1259 CalRecycle E X A M P L E 1 2 3 _ Comprehensive Tri Number , Snrearcaerom+. 4568536 c ma�td•av(7/lgINSTRUCTIONS ON BACK'OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE By signing this CA Comprehensive Trip Lop and Receipt,Nform will signer(s)request that the Information provided on this forwill be considered confidential,proprietary and trade secret In accordance with Title,14 CCR,Section .17041 at seq.,H a request Is made for disclosure of this Information,CalRecycle will contact the signer(s)of this term at the address and telephone number provided on this forth or receipt Vehicle Information Truck Decal Number Hauler Address Business Name C C-R TRUCK TIRE CENTER Address 11 M O 9979 Cherry Ave., City,State and Zip License Plate Number State Fontana, CA. 92335 2 HE © ®'rd K1 n H Carrier..n L � _j. I certify under penalty of perjury under the laws of the Stela o1 CaLlpfrl t the information provided above is true and correct.In addition,I am aware that falsification of this inform U0n may result in suspension,revocation,or denial of renewal of. the Waste Tire Hauler Registration pars Public Resources Code sec0 42.()and may result in civil penahies up to ll 25.000 per day.per violation or administrative Penalties up to 55.000 per violation per day as described In Public Resources Coda sectlon 42902 .. Driver's Name(print) 7. Driver's Signature Date Comprehensive Trip . . Number Load Information Facility Tire Program 0 4 5.6.8 5:36 Pick Up Delivery U �D a� Facility Telephone.Number v Hauler Tire Program ID / Site Suffix DATE Liu* [:]Weightoaa aoaaaaa � a a Whole The Count In Ltrs. , Facility Business ' El Volume Cubic Yds. D Weight in Tong .Name/Address E -City,State.and Zip .. o -Hauler Name v a. Stamp or Label OK Hauler Telephone Number ■ Address:Same as.Hauler Initials (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix .- 4568536 -- BPick Up. Delivery . M 2 D-� N N � LU1. 0 _ Q _ Hauler Tire Program ID / Site Suffix Facility Telephone Number' w DATE [6�./ PCS / H[2C c Lu Whole Tire Count. Weight in Lbs: Fa r ass 11212.PH 1 Volume Cubic Yds.,E]Weight in Tonsr 5Add efASes' c City . a Ip NE CENTERS U _ Q � Stam ' ■ A dress me as auler Inirr Q — (N/A for 1 R FY THAT UNDER PENALTY OF PERJURY OF THE Yl Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. - ompr omprehensive Trip Log Number Load Information Facility Tire Program ID Site Suff ix CL 4 5.6 8.5 3 6' . .:_ A: Pick Up Delivery N � MNR[d . 0' -d Hauler Tire Program ID / Site.Suffix _ Facility Telephone Number cc DATE D . . . - . . Lu,a Whole Tire Count . E] Weight In Lbs. L 1 fT 1 — 1011 "` Volume Cubic Yds. ❑Weight in Tons• .Nadme7 SSS Q1V �,�� JC i o au er Name City,IS ..e�rt(t" NM)NI S )I y 6CR TIRE CENTERS '�� C U auler !" pdStamQ Ai11 te aG IW Initials■ � (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE t INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.