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Dept.of Resources Recycling and Recovery'
<br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box126d,Ssdrelnonto,CAB6612-1260
<br /> C�IReOut ccig X a M P i~ 1 2 3 r ' Com rehensive Tri Number
<br /> c,sccr�riTo���ro�INSTAUCTiONS ON B4O.CK�O.F pART 2 p0 NOT TAph,.STAhLE OR DUhLICATE • •
<br /> 'DyatpnhO lhle QA COnIpIa11/nelYe T Ip LOU and Reoolpl,Ihe.elBner(e�ragMt that tho Inlormellon provldatl on.ihle form WIII bo oongdlrod doANd/n11oi,proptldory antl Indo saerol.!n a000rJen6a with Tllle,l4 COR,Soollolt+
<br /> �1 t041 el f a roq,Mt 11 Meda for dleolalaro of thU lniormellbnr Calmayal o will contact the alBnerU)of lMli leFm al the oddreae and labphdMa number provided on lhb lorm or reeelpl.
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<br /> rt`CIDI(abQ �r�u @r: , +h- t=i�4�''� `'r �1 r,.•'i! Fiaulor Address I E.r'/'/!J�^ f�� (�']
<br /> k3usiness Name r f1J V
<br /> � i"!ice � �• /address
<br /> t=- n,9, City,State and Zip
<br /> .ldbnSs,, $rNutxi,Ad:,; ;. a., iryCjtate > 7>di,
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<br /> I6WE undot p/ndlly orporfury under the l�O61 the Slele of CalifairWhal the Information provided above le bue end eorreal.In edalon•I am avue that falel0o�all
<br /> Ihln lnfofmmron may w3uh In euepepelon,ravoea"'r'ordam" rorwvtal of
<br /> Bro Wath Ike Hauler Reg4lrallon punuen Publlo lleoourcoe Code/Aallon. OOD orA ray raeeft In CMl ponelUos up to$26:000 per day,plGvlolallon or odmhpenelllee up fo55,Ob pervlole0onperdeyae delwBYed In Puhlla�Roeouraoa
<br /> Code ,42002
<br /> _ Driver's N me(print) 15river' gnature Date
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<br /> Hauler?ireProgramlp / SiteSufflx Ill Telephone.
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<br /> Healer Namo �? City, i'tcffe fl 41'.�.i(:r
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<br /> Hauler Tolr3phane Numbor Address Same as Mauler —�
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<br /> {�.,., `-ICERTIFY THAT UNDER PENALTY OFPERJURY Oflife
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<br /> (r �'rl t T'fh01r9� §1;'N LAWS OF THE STATE OF CALIFORNIA THAT THE
<br /> i i�f.�t - +L.� i5 :h.,,,. i.nn w't�t. n INFORMATION PROvIDEDADOVE IS TRUEAND CO RECT
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<br /> 5757703 ...� ❑PfkU,p .Dlivery.
<br /> 61 Hauler Tire Program ID / Site-Suffix Facility Telephone Number.FOI
<br /> �r: J'a��0000
<br /> �- w YJh_le Tire.Count-:[]`.,`eigI, in I f)S
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<br /> 'S L'AlZ law N1EGtbr 1 r' (CERTIFY HE STATE
<br /> UNDERPENALTYCALIFORNIAOF THAT.
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<br /> LAWD OF THE STATE OF CALIFONIA THAT.THE �
<br /> r...,..,• R INFORMATION PROVIDED ABOVEIB TRUE AND CORRECT.
<br /> :--.-Comprehensive
<br /> Log Number
<br /> Load D Site Suffix
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<br /> -5757703
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<br /> ,Hauler Tire Program ID
<br /> 1 sooyad
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<br /> Hauler•. lItje'''u• �, - - r yrs +
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<br /> �/� •?�NlEyvA 3,•` )}�+ a(r LAW80FTHE STATEOF CALIF.OANIA THAT THE {
<br /> LC (( �� ~f �' - -�• •+ L�' l t •r'Hit4 'A <q, INFORMATION P96VIDED ASbV91S TRUE AND CORREO,T. +�
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