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Dopt.of Resources Recycling and Recovery <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 98812-1259 <br /> CalRecycle ( x A M P L E 1 2 3 Comprehensive Tri Number <br /> t a•;a-� <br /> c ma.,m mINSTRUCTIONS ON BACK OF PART 2 DO.NOT TAPE, STAPLE OR DUPLICATE 110!w ' <br /> By signing this CA Comprehensive THP Loo and Receipt.the sialerlal request that the Information provided on this form will be considered confidentief,proprietary and trade secret.In accordance wtth Title,1e CCR.Section <br /> 17041 at seq.,H a request is made for dl-lasurs of this Informotlon,CalRacycle will contact the slgnv(s)of this form at the address and telephone number provided on this form or neNpt. <br /> Truck Decal Number Hauler Address F�LL[[ j jwqu(yl �vnu{ ! vGc Jl(fy1 �t <br /> Business Name <br /> Addresa <br /> License Plate Number 2 )) State City,State and Zip <br /> D . 3 I C ❑ Common I ��� C44- �< <br /> Iq E k a. .. Carrier l— <br /> I certify under Density of perjury under the laws of the Sato of California that the information provided above 4 th t and caret.In addition.I ern aware tl'ot falsYflcabon ofyslsAMonn;tiRM 81ByfesstN e0epefRlpn,revocetlod.or daniel al recewal of <br /> the Waste Tire Hau'ar 13@p;station pursuant to Public Rexmrcm Code section 42980 and may reudt In civil psnaluee up to E 25,000 par ay. or vic tlen pr atlr 311ve p arias p 5.000 par vlolh on ppr day as dosrxlUed In Public Resources <br /> Cade a tl 47�9yy7 <br /> ZK ov I MMA&5 cWe, 1711bhT <br /> Driver's Name(print) river's SI nates Date <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site SUff iX <br /> 5733014 -- C Pick Up , Delivery a <br /> ID Haulsr Tire Program!D / Site Suffix ' <br /> Facility Telephone Number <br /> �• DATE <br /> N 000- aaoaaoa <br /> a Whole Tire Count Weight in Lbs, <br /> Facility Business <br /> Volume Cubic Yds: Weight in•Tons Name/Address <br /> o Hauler Name City,State and Zip <br /> � Q Stamp or Label OK <br /> Hauler Telephone Number ■ Address Same as Hauler T <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whela Tlres? LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE 19 TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID <br /> mss. <br /> 301f� -- B Pick Up ffix <br /> Delivery a <br /> aulerTire_Pr gram I / Site Syffix a©. a© .Facility Telephone Number • <br /> .. (P . P-11 lvkrt7 �hSr.1✓!{/b�' DATE <br /> _W _ P5RON <br /> PD p�, <br /> E e�UX J wa �Whole Tire Count Weight In Lbs. � <br /> L�#o o'E'l(�'03_1 I' ` ire Qpm W�� <br /> `1l ` _ ,p! / a Volume Cubic Yds. 11 <br /> WDfght In Tons N 1n cr rest <br /> c r 0/rf �Ql��jj/D/PCt `'' j /� <br /> ao S � 3 j S1 tp or'Lael QK <br /> Hauler Telephone Number ■ E:] Address.Same as Hauler. r r, <br /> aG {N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> '�a f a�oCJ Whole Tilos) LAWS OF STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> a <br /> 5733014 -- A Pick Up Delivery ' <br /> nI <br /> sestet Tire Program ID / Site Suffix FiN <br /> Facility Telephone Number <br /> Spu4vl n �ilii l&-a✓ DATE ©® <br /> C: (. 011 4 w ® Whole Tire Count ❑ Welght in Lbs: <br /> g $Ifv[ <br /> to 11 1 a ( } <br /> �of I D Volume Cubic Yds. Weight in Tons {4`1 r{s J!dr ` <br /> o u Ler N 7d Ci ant(LXX <br /> Gr!1 y, � aEDE T ' 00 <br /> Stamp of La e �K <br /> Hauler Telephone Number ■ Q Address Same as Hauler „cera/, <br /> {N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE jl <br /> Whole Tlrosl <br /> pi.- /� LAWS OF THE STATE OF CALtFORN1A THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. �'�I <br />