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' . 2! / Dept.of Resource.Recycling and Recovery <br /> CA Comprehensiv�e�rip- and Receipts 10002 P•O.Sea,259,3ecremento,oA959,2_,2a9 <br /> r Com rehensive Tri Number <br /> CWRecycle EXAMPLE 1 2 3 , <br /> caur mplim(MilvINSTRUCTIONSI ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE ' 49978�` <br /> ,• By signing this CA Compnhenetw Trip Log and Reosipt.the alpner,el request that the Informprovidedno wi <br /> eUon on this fall be ooneldwW aardklentlel,praprf•tmee <br /> y end trade onL In seeordenee with Title,14 CCR,Section <br /> 17041 at seq.,N■request Ia made for disdoeun of this Informatlon,CafReeycle*All contact the aipner(s)o1 this form at the address and telephone number provided on this tam or receipt. <br /> Vehicle Intormatlori � .S' ' <br /> Truck decal Number Hauler Address ��� DGrq r p„i�{ CG.i?SPYtiG �ic <br /> © © Business Name <br /> Address 11 <br /> City,State and Zip . ��U• "J� 2_ 1303Z) <br /> License Plate Number State <br /> Cue <br /> ❑ <br /> 0 Common <br /> E.H. <br /> Carrier _ 1 <br /> I cenlfy under penally of perjury under the laws of the State of California that the Informals provid abpvs is true end correct.In additlon,I am.wora that ralelfltatlon of thin Informatlon may resuit In suspeaslon;revocation,or denlel of renewal of <br /> the Waste Tire HaWm Registration pursuant to Pubil Raascea Cafe section 429110 and may_uN rd,,penalties up tti$25,000 Per day,per vols on or admini alive penslties up to E5,DOO per violation per day as described In Pupil.R-- <br /> God. <br /> eeou - <br /> -114t-- <br /> Driver's Name rant ' t i" ;i Driver's Signature Y" ( ` Date <br /> Comprehensive Trip Log <br /> Facility Tire Program ID Site Suffix <br /> 4997881 =- EE� a r0 D D -0 0 <br /> ck Up'.�•• Delivery <br /> + <br /> Facility Telephone Number <br /> -Hauler TireProgram ID •/ Site Suffix <br /> • � � DOD- 0000000 . <br /> a Whole.Tire Count E] Weight In Lbs. <br /> � Facility Business <br /> 0 Volume Cubic Yds. ElWeight in Tons Name/Address <br /> p 'Hauler Name - City, State and Zip <br /> 3 Stamp or Label CK <br /> Hauler Telephone Number ■ ❑ Address Same as Hauler <br /> INAfor I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> h ' Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> ta INFORMATION PROVIDED ABOVE 19 TRUE AND CORRECT. <br /> .ever <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> .4� y <br /> 4997881 -- R. � Pick Up ' Delivery NNE- NMEN <br /> as <br /> -a s <br /> Facility Telephone Number. <br /> ✓ Hauler Tire Program ID / Site Suffix p <br /> U �� 'DATEH_ nMRRR7 o o © PC <br /> osi gS21 F3 a ®Whole Tire Count Weight to Lbs. t <br /> � -7 7 <br /> Volume Cubic Yds. Weight in Tons Name i 1 <br /> Hauler Narge City, r a p '�✓1 °('S <br /> ?1123 4 . C,D�eIRGe' ��• <br /> ■ D_Address Same as Hauler <br /> 'Hauler Telephon Number .. Ln)(r& <br /> I 7 r1 i�i—vfq (Nle it CERTIFY F THE STATER PENALTY OF CALIFORNIA THAT THE' THE <br /> L (z Whole7lrea) '.1 <br /> INFORMATION PROVIDED ABOVE 13 TRUE AND CORRECT. <br /> Comprehensive Tr • Log Number Load Information Facility Tire Program <br /> 4997881 ass- A [7PiCk Up Delivery. Ll [31 ® ® N M- a <br /> tiHauler Tire Program ID' / Site ffix DATE 6 Z Facility Telephone Number <br /> N , I � �i senAV , DO � a� � O© 2 <br /> p.�921�,D?d "� DDD oa00 � 0 ® <br /> @ Stbc b>11 C A 9�2-13 : a• whole The Count Weight In Lbs. <br /> Fac_illt r la.TcSS,Sssc h,q Ord <br /> I El Volume Cubic Yds. ❑ Weight in Tons Na e/ ddres^ <br /> E Hauler Name Cit r�lc+ �nZipRf ��r.1- I Jam' <br /> oY ` Stam or a E Oh i <br /> Hauler Telephone Number 1 ■ Q Address Same as Hauler „„ar <br /> ,.,• V�•f �y i� ��.r ��\ - (Nle for 1 CERTIFY THAT UNDER PENALTY CALIFORNIAPMURY THAT THE THE LL Whole Tlroe) LAWS OF THE S7AE OF CALIFONITHAT THE <br /> INFORMATION PROVIDED ABOVE 19 TRUE AND CORRECT <br />