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' Dept.of Resources Recycling and Recovery CA,Comprehensive Trip Log .and Receipts 10002 P.O.Boa 1259,Sacramento,CA 9M12.1259 Comprehensive Tri Number calsecycte EXAMPLE 1 2 3 - . : - � �.R �. ,,.,j.,;, . rage 'wINSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE 5 �32' 51 By along this CA Comprsh Instya Trip Lop and Receipt,the signers)request that the Information provided on this form will be considered confidential,proprietary and trade secrat.In accordance with Mi.,14 CCR,Section 17041 N seq.,N a rsgtrnI Is made for dlscloeure of this Informadon,Calliecycle will oanact the M .lgr(e)of this form at the nu address end telephone mb•,provided on this form or r Ipt. 1104,11"q il"uss' Vehicle lntormatlon ~Truck Decal Number Hauler Address n Business Name I : r ;€,� T •1� ® � �`©'® �•. � ' Address .,` >,' License Plate Number - State City,State and Zip nn G � ® �. .� ®Y 0 Carr Bron � � � , . C1 c RM J cani'y under penalty of penury under the laws of the State of Caldor.•that the Information provided above la it..and correct.In addition,I am aware that Islsillcel a Is Inf ay n suspeml rovocatbn,or denial of renews!of the Waste Tile Hauler Registration pursuant to Pudic Resources Code section 429W and may result in civil penalties up to S 25,ODO per olatbn drnini {x r violation pe ay,as desral In Public Raeourcea Grade Section 42961, t �� AA 4-11f I� 4-11 fa A . Driver's Name r€ret river's Si nature Datek, r LComprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 5-7 3 2 9 61' -- 'C Pick Up iDelivery, o - Facility Telephone Number cc Hauler Tire'Program ID / Site Suffix DATE / oo / o 0 LU WDon- 0000000 �. hole The Count Weight In lbs. g FacilityBusiness Volume Cubic Yds. Weight in-Tons, Name/Address cc Hauler Name City,State and Zip N U - Stamp or Label OK Hauler Telephone Number ■ o Address Same as Hauler r (NIA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE • Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION N= ABOYfi IS TRUE AMD CORRECT. .77 Comprehensive Tr • Log Number Load Information Facility Tire Program 5732961a -- B F-].Pick'UP Delivery U Facility Telephone Number Hauler_Pq Porto am D / its Suffix DATE lull 02, / E© UPSpit / w�®� ole The Count. D Weight In Lbs. . loll l ❑Volume Cubic Yds. []Weight in Tons + tt oL:)HaLoer Name aYA . � SJ �It7tY1 i I.onse��fi,x�.G� �G.�•-�h: C,Re- �-�'SZvCo V Z Stamp or Label OK � 000Rip Hauler Telephone Number 0 Address Same as Hauler ��s�.c +�►^� (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE •r�f[i�f � i /v O - - Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE . l�'- INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT, Comprehensive Tr • Log Number Load Information Facility Tire Program -� 5732961 assas A Pick Up .TT Delivery• ® 19 ®—.R M i Hauler Tire Program ID `/ Site Suffix Facility Telephone Number coils w g , 'DATE. / D� -oaf Whole Te Count Weight in Lbs. , 11 Fa-j 1 t d —1 �! C) I Volume Cubic Yd'..[] Weight in Tons �d Tel c Hauler Name Md. k� T LJ lie ur�t t �-a v 2 Stamp or Label OK Hauler Telephone Number Address Same as Hauler I r Is `-�• ��O O (N/A for I CERTIFY THAT UNDER PENALTY PERJURY OF THE W_C�If hole Tires) LAWS OF THE STATE OF CALIFORNIACALIFORNINI A THAT THE INFORMATION PROVIDED ABOVE 13 TRUE AND CORRECT.