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<br /> Comn rehenslve Tri p•Number
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<br /> rarekyrltro°pifB)INSTRUCTIONS ON'BACK'OP PART 2 D0-NOT TARE.STAPLE OR DUPLICATE
<br /> / By signing this CA Oomprehonolve Trip Lop and Receipt,the elgmdsJ prg0est that the Informallon provided on this form will be conslders4 confiden9al,proprietary and he do socrel.In accordance vilth TIUe,14 OCR,Section
<br /> l 17041 pt..q.,Ir a raquest Is made for disclosure of this Information,CalRecycle will contact the dgner(e)of this form at-The address and telephone numb or provided on this form or receipt,
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<br /> I•codlty under penaltyof poduryunder the lows of the Slots ofCalifornia Thal the Infonnallon provided above Is true end consel.In addition,I am awve that ielsi6oaUon of ehlsInfonnallon ma}rtesutl N auspensloh,revoiallon,or dental of renewal of
<br /> the Waste Tire Hauler Regislmllon pursuant to Public Resources Codas lion 42960 endmay(out[In chil penalties up to 526,000 per d y5 Iollon or administrative pe' ties up to$5,000 per Violation per day s described In Public Resourcr
<br /> Code asell.429 B2
<br /> _ Driver's Name. rli7t,. - Driver's Signre
<br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID site suffix,
<br /> -i 56307-58 -- C �;,Pie.k U,p D'eiiVery a © � ®• L_
<br /> V- Hauler Tire Program ID / Site Suffix Facility Telephone Number
<br /> DATE
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<br /> Hauler Telephone Number r ❑ Address Same as Hauler Initials
<br /> n 23 I , (N/A for I CERTIFY THATUNDER PENALTY OF PERJURY OFTHE ypppiia
<br /> ~ Y Whole Tires) LAWS OF THE STATE OF CALIFORNIA THATTHE
<br /> INFORMATION PROVIDEDABOVE I$TRUEAND CORRECT
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<br /> Facility Telephone Number
<br /> Hauler Tire Program ID / Site Suffix DATE
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<br /> Halder Telephone Number ■ I_� Adr1l'ea s San-te as Hauler rnrrrar5
<br /> (N(Afor ICERTIFYTHATUNDERPENALTY OFPERJURY OFTHE
<br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THATTHE
<br /> INFORMATION PROVIOEp ABOV ISTRUE ANO CORRECT.
<br /> Comprehensive Trip Log Number Load Information Facility Tire Program
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<br /> da Hauler Telo hone Numt�eh ''l i. dres�Same as t i�u(er Initials
<br /> !��ta 5' !< L ,�+ '{ ,1.-r6•S, (CERTIFY THAT UNDER PENALTY OF PERJURY OFTHE
<br /> r)/-� I`,;.�S'1'j -,.:Y4:, i r r'-_'.-0{}.,j� jr. 7,u'ty`aJ`.,I �j•.p1 ?
<br /> '1j r ( /'J "4 {d.(j,'� �Yai,i�oi 'i-:h"r"ri:•4''{�i!ri3Mh�('r�f, ,5: LAWS OF THE 97A7E OF CALIFORNIA THAT THE f
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<br /> i�'t .�.li•.-tiz�'§, INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. � iy%af-ti
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