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Toll Free 1-866-896-0600 / www.calrecycle.ca.gov/Tires/ <br /> CA Comprehensive Trip Log and Receipts DePBoxt.of 125Resources mentoRecycl,CA 95812–g and vcry <br /> 10002 P.O.aDX Tzss,Sacramento,en sselz-lzss <br /> C81ReCycieLE-jXjAjMjPjLjEj 1112131 _ Comprehensive Trip Number <br /> stareercarroma <br /> �a,Recyd, . III)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE.STAPLE OR DUPLICATE <br /> By signing thls CA Comprehensive Trip Log and Receipt,the signer(s)request that the Information provided on this form will be considered confidential,proprietary and trade secret.In accordance with Title,14 CCR,Section <br /> 17041 et seq.,II a request is made for disclosure of this Information,CalRacycle will contact the signers)of this form at the address and telephone number provided on thin form or receipt. <br /> Vehicle Information <br /> Truck Decal Number <br /> License Plate Number State <br /> 111100 o as I � (rl`lliiiil! Il <br /> I certify under penalty of penury under the laws of the State of California that the information provided above is true and correct.In addition,I am aware that falsification of this information may result in suspension,revocatlon,or denial of renewal of <br /> the Waste Tire Hauler Registration pursuant to Public Resources Cade section 42960 and may result In civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources <br /> Code section 42962 <br /> Driver's Name(print) Drii er's-Si nature Date <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suff ix <br /> 4596079-- C a Pick Up [delivery <br /> Hauler Tire Program ID / Site SuffixFacility Telephone Number <br /> DATE 00 <br /> �� <br /> (L Whole Tire Count Weight in Lbs. <br /> aoo o © a000a <br /> tti <br /> t <br /> F1 Volume Cubic Yds. 11 Weight in Tons !:k' i ,1. <br /> E I `�; f r i �I Palogix <br /> o i, I, i.': I 1 r Supply <br /> � _ l <br /> U in <br /> 1 . } ¢ <br /> Initials — <br /> / i.- I t e l i I•"-- / I (NIA for I CERTIFY THAT U N DER PE MALTY OF PERJURY OF THE <br /> /' --J r �•`/ i ( / Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> 1 1 I\\\ I '� INFORMATION PROVIDED <br /> JI ABOVE IS TRUE AND CORRECT, <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> Pick Up ❑ Delivery a s <br /> Facility Telephone Number <br /> Hauler Tire Program 1D / Site Suffix DATE <br /> ul Whole Tire Count F] Weight in Lbs. <br /> DDO- 000ODEB <br /> Volume Cubic Yds. Weight in Tons <br /> !�;..1"I `j� It.I= II(.4r11 L1 C.i _ – ■ -f I I !tL - - !II ,�,-I ! .I Initials --. <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE rt <br /> i 1 f Whole Tires) LAWS OFTHE STATE OF CALIFORNIA THAT THE i•i L.' <br /> INFORAIATION PROVIOEO ABOVE IS TRUE AND CORRECT. 1 <br /> Comprehensive • • • Number Load Information Facility ID Suffix <br /> - <br /> 4 5 9 6 0 7 9 -- /0► Pick Up Delivery <br /> v Hauler Tire Program ID / Site Suffix �a a Facility Telephone Number <br /> DATE I aa � ` aoaaaao <br /> a Whole Tire Count ❑ Weight in Lbs, <br /> Volume Cubic Yds. Weight in Tons <br /> E <br /> Q _ <br /> Initials <br /> iN/A for ICERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> f 4WA or <br /> TNF STATF nF r:At IFORNIA THAT THE <br />