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Dept.ofResources Recycling and Recovery <br /> CA Comprehensive Trip Log and Receipts 10602- P.O.Box 1259,sacrumento,CA95812-1259 <br /> Com rehensive Tri Number <br /> CaftyaB E X A M P LIE 1. 2 3 4. .r,;. , ;. <br /> INSTRUCTIONS ON BACK DEPART 2- DO NOT-TAPE,STAPLE OR DUPLICATE '-F f; J r` <br /> spn4,9 thb CA CAmpnMnrw Trip Log and Receipt,Ow WW—ts)requarl Met the Ulf orr.U.Provided c n&d.form wi•W ownidere,d caAU•nUal,proprl.tm and bads.wilt In a000rdarrc�.ad.ntb.14 CCR,9•ctbn <br /> •1 1•t s•q.,ff•request be ,Gd on Bie fm or reeiptr <br /> Vehd <br /> icl <br /> Information �•— <br /> Truck Decal Number Hauler Address I S 300aU IN Reg 10116t 1 eoN se'r IK to r� <br /> Business Name <br /> { <br /> Address x 2�'250�0 i C <br /> MR — ONFE City,State and Zip <br /> Licensee Plate Number State ref !-rl}� CA Cr(K 2 <br /> CaLJrrier <br /> on <br /> ier <br /> I certify iande,r penally of P jLvY order the,Wv of the Stns of Ca6tomb$reel the Ivonrutlon provided•hove is true and correct In add:tion•I am•wv that fabircation of thi.Information may result in wsparpgn,r•eece,llon.or denial of raf»wtl M• ' <br /> the Wane Tim Hauler Repistrahon MIMM"to PqkRrrso'M Code,section 42980 and may result In ctA pe,rWlies up to$25.000 pier day,M v10b or eaJnbastM up to$6.000 pr vlabtlon per day as described in Pubk Resoruc" <br /> Ccd.ee,ctbn 42962 1 <br /> Driver's Name' riDt I ' Driver's Signature' "bate <br /> Comprehensive Trip .. Number Load InformationProgram <br /> a �•5'5r,5 8 6 9 -- Pick Up Delivery <br /> Hauler Tire Program-ID"/ Site Suffix ' 'Facility Telephone NumberDATE <br /> t <br /> ala-a0000aa <br /> ro r wa 1:1 Whole Tire Count Weight in Lbs.. <br /> Facility Business <br /> E]Volume Cubic Yds. 0-Weight in Tons . Name/Address ' <br /> c Hauler Name City,State and Zip <br /> 3 a Stamp or Label OK <br /> U <br /> Hauler Telephone Number ■ Address Same as Hauler . Irr Is <br /> • - (N/A for 1 CERTIFY THAT UNDER PENALTY OF PERJURY OF THE, <br /> i Whole Tires) LAWS OF THE STATE OFCALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE 16 TRUE ANO CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 5545869 -- B Pick Up Delivery <br /> Hauler Tire Programa ! Site Suffix <br /> Facility Telephone Number <br /> Sc�',,Soci Ad 1 N kQ ionL` DATE 0 / / <br /> cn�S��u�1�h �Gt Ps r MEREQU <br /> P ` 2`� Q�(� 21�j w © Whole Tire Count El Weight in Lbs. <br /> d � jh CA �1S a F-tc ' B nes <br /> ` IS Volume Cubic Yds. Weight in Tans /X�s ,(alJ h�y <br /> o Hauler <br /> lQhpeywn Joayu'[l'�! _ Qt"2q <br /> �vn� ,✓a Firs OEOEE� EE ' o <br /> Stafi�.�ipKHauler Telephone Number a dress,Same as,Nauler. . rnrner <br /> (N/A for •I CERTIFY THAT UNDER PCALIFORNIAPERJURY OF THE•, <br /> 018 1 Whole Inres) <br /> LAWS OF THE STATE OF.CALIFONITHAT THE <br /> INFORMATION PROVIDED ABOVE 13 TRUE AND CORRECT.•. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suff ix <br /> 5.5.4 5'8'- 11 6 9 -- A }( Pick Up Delivery ' I MEIN E M '� <br /> -- ©: <br /> Tire Program ID / Site Suffix Facility Telephone Number <br /> Hauler <br /> y SG►T►,�OGC{IA I r1 �P.�14t'1L1 L DATE ®a /•© �� / Mg <br /> . <br /> lx 21�iO3 a ®Whole Tire Count Weight in Lbs. <br /> � - S•t•pC .����•gs21� S!N J MiWf l,41 14Volume Cubic Yds. fA <br /> lf <br /> o Hauler Na e.SGtYI ,j d n��i�i i;Gtlsl�tel�Zip - i <br /> 2oglona� C0NS04VLk r Its 150 VI{ �1� RD,St(k -A <br /> V Stamp or Label�r% r <br /> - <br /> Hauler Telephone Number. 4 ■ ' Address Same as`�}.Hauler ;,hi;,; –•� ., <br /> (N/A for 1 Y THAT UNDER PENALTY PERJURY OF THE ; <br /> WhOWholeTires) lAWS AMf9 OO P THE STATE OF CALIFORNIAI THAT THE•.•-;.: <br /> INFORMATION PROVIDED ABOVE 13 TRUE AND CORRECT. ` <br />