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Dept.of Reeouroes Reoyeling and Reoovery
<br /> CA Comprehensive.Trip Log and Receipts 10002 . P.C.Box$269,6eoramedto,.0ASISM-1269
<br /> CalRgC G1e E X A M P L1 2' 3 Com retinsive Tri Numb r
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<br /> cnllrnae0 no)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE.STAPLE OR DUPLICATE
<br /> r 9y stoning this OA Oompx/hanalve Trtp Lop sntl Re0eIp1,Iha al9n/r(aJ rogwat that Iha Information prevldod on Ihb tehn wIU Do gonddered eonlIdontrel,pmptl/Ury and Dads mord,In aoaordsnoa Whh TIIIo,to 00R;$O011on
<br /> 1 17041 H iiq„Ito roquol la made fordiscloauro of Ihfa inlonnallan,CdRoayCIO WIII OObtain the Npnar(s)of Ihb loan al lho sddre�s'pnd tal�phono nOmbor proyldod on this fpnn or noaip6
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<br /> i�uC1x1I3caiNi,mner - Hauler Address � 5 .��� ��
<br /> BLIsiness Name ` t 1..,
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<br /> Li6eei3 Plate:Number state City,State Eil1d zip
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<br /> 1 caril y under W.1h,of VA y undw Iba wive of Ihb$IS10 of CaRlomfa that U,4 Inlormallon provldad above Is Irub and correct.In addition,I am SWIM that fMlNfloatfOn Of this InlwmoUOn may romp in mapae.ton,rovoolligd,of P.W.l Of tansvral d
<br /> Iha Wella Toa tlaihr Ragsu.tion pu,mant to Pub$v Ra.ellrcal CQde saoUan 12000 andmay resull In Olvll ponalties up to$26,000 per day,poNolelfon m ad,nfnlslrO11%Penalties up to$0,000 par vlolaUon per day at dOlmibdd In Publio Wourca..
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<br /> Driver's Name: prin Driver.'s Signature std
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<br /> Load
<br /> am ID Site Suffix
<br /> 5757
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<br /> <j Hauler Tire Program ID / Site Suffix J '"> � OEA. l Facility Telephone Number
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<br /> Hauler Namo � � = p
<br /> Hauler Telophonb Number ;. pi, l�ddreas Same as Hauler rnruar5
<br /> I.CE911PYTHAT UNDER PENALTY OF PERJURY OF THE
<br /> { y7 LAWS OF THE STATE OF CALIFORNIA THAT THE
<br /> .— ' „t r;'. ..r •tsf-f�.'Jr'#�i:! INFORMATION PROVIDED AOOVE IS TRUE AND CORRECT.
<br /> / 1 1 11Numb' .: • • la
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<br /> 5.75770 -- B Pick Lip,
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<br /> ��yv! Hauler Tire Program ID / Site Suffix �� Facitiiy Telephone Nufinber j
<br /> t- a l®Wholo Tire Count Wolght In Lbs
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<br /> (: t Hauler Name
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<br /> Hauler Toletiltone:NumUer ,g � A g �-•
<br /> t•' a_ r,+..•y:'f I COTIFY THAT UNDER PENALTY OF PERJURY OF THE
<br /> [ VCQ —he, •,� f~� Y�Itnlaflf'R LAWS OF THE STATE OF CALIFORNIA THAT THE
<br /> •''"`'I ,;Y....',. .INFORMATION PROVIORO A90YE 13 TRUE AI D CORRECT.
<br /> Comprehensive TrIptog Number I Load Information Facility Tire Program ID Site Suffix
<br /> 1 1 1 a 0�
<br /> JL
<br /> Huier.Tir's.Rrogrern.tD / SI#eSUf�l 1601' !N
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<br /> il: .:t l N.t1�.i?1r{�� 1'x � + Tl#I i d,, 4,1 � _•,� 'r`'.i C �1 C 1 iv =
<br /> Hauleu 7e1ej51tone Num�ipr _ - r1dI,¢ ��i" s Haulei: I Na/
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