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OV-091 / UUVVUV.VCA1II%rVIV•y.vu.woi aas— <br /> Dept.of Resources Recycling and Recovery <br /> CA Comprehensive Trig Log and Receipts 10002 P.O.Boz 1259,Sacramento,CA 95812-1259 <br /> CaftCycle I E I X I A I M I P I L I L I I 1.L2131 Com rehensive Tri Number <br /> stat.of Cafromta <br /> callfacyue2alonmlNSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE <br /> By signing this CA Comprehensive Trip Log and Recelpt,the signer(s)request that the Information provided on this form will be considered conlidentlal,proprietary and trade secret.In accordance with Title,14 CCR,Section <br /> 17041 at seq.,If a request Is made for disclosure of this Information,CelRacyale will contact the signer(ii)of this form at the address and telephone number provided on this form or receipt. <br /> Vehicle Information <br /> Truck Decal Number ; <br /> License Plate Number State <br /> i <br /> a a a a a a a <br /> F-111 <br /> f Oral' olil <br /> I rectify under penalty of perjury under the laws of the State of California that[tie Information provided above Is true and correct.In addition.I em aware that falsification of this Information may result In suspension,revocation,or denial of renewal of <br /> the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to S 25,000 per day,per violation or administrative penalties up to$5,000 per vialat[w per day as described in Public Resources <br /> Code section 42962 <br /> i <br /> Driver's Nameiiijjwtl Driver's Signature Date <br /> Comprehensive Trip •. Number Load Information <br /> x <br /> 4796505 -- C <br /> Pick �p L <br /> Delivery o_o 0 0 o a o a <br /> v - Facility Telephone Number <br /> H81-llel•Tire Program ID / Site Sufti)( <br /> cc <br /> ,, � a� aaao � aa <br /> W a Whole Tire Count Weight in LbsCL . <br /> - I I 0 Volume Cubic Yds. El <br /> Weight in Tons <br /> J—i 1 t <br /> I U SIL,. Ivslliv l / I <br /> 13au[et'Tee(tl2ci(5 ( til, ,::.: l _I r7H <br /> — (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE I/��1Whole Tires) U1WS OF THESTATE OF CALIFORNIA THAT THE <br /> 'Df I INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip L• sumber Load Information c Program <br /> ooaoao-o <br /> B �Pick Up �eli�re U - o-- <br /> �i <br /> Facility Telephone Number <br /> I r� mauler Tire Program ID / Site Suffix DATE a <br /> � I W 11 Whole Tire Count Fl Weight In Lbs. Dun OnOEEPO <br /> cu a <br /> F1 Volume Cubic Yds. Weight in Tons f �' <br /> pt4let'I11dIttE•. It <br /> (ilCr F,!( ( _ _t i ❑ (N/A for ; .:111. Initials _ <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Wholc Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> i <br /> omprehensive Trip Log Number . Information Fa Progra <br /> t <br /> 4796505 -© Al El <br /> Pink Up E <br /> Deaiverry U E UDUE-D <br /> o �a <br /> Facility Telephone 6�tarnber <br /> Hauler Tire Program ID / Site Suffix DATE a a <br /> N • Baa aa � aao � <br /> W � Whole Tire Count � Weight in Lbs. <br /> Palogix Supply Chain <br /> Volume Cubic Yds. Weight in Tons <br /> nL— <br /> in t- <br /> 0 Q <br /> CEInitial <br /> I -- - <br /> (N/A for ( RTIFY T1iN UNDER PENALTYOF PERJURY OF THEWhole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORM1IATION PROVIDED ABOVE IS TRUE AND GORREGT. <br /> 1-_ <br />