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Dep Reso es and Recovery CA Comprehensive Trip Log and ReceiptsP.O. of 1259,Sacra06' to, A95812—'125 10002' P.o.Bell�25s,Sacramento,CA 95812=1259 Comprehensive Trip Number 1Ca1RecyC1ejEjXjA,jMjPjL'jEj-- 1112 '3 wmw r ra,.wcae . ��478 . varae�u,r7norINSTRUCTIONS ON BACK OF PART2 DO,NOTTAPE,STAPLE OR DUPLICATE By elgning this CA Comprehensive Trip Log and Receipt,the signer(s)request that the Information provided on this form win be considered confidential,proprietary and hada secret In accordance with Title,1•CCR,Section _ 17041:et seq.,H a request Is made for disclosure of this information,CalRecyclo will contact the signer(s)of this form at the address and telephone number provided on this forth or receipt Vehicle Information Hauler Address Truck Decal.Number ® ® aBusiness Name �T.T,.,�.,• o.C MANUFACTURING as C` Address TIRE RECYCLING DIVISIONa City,State and Zip Stat License Plate Number5$2-Harbor Blvd e NEED ElflH ❑ El Camero on • �� i9869$04 ��6�� I certify under penalty of perjury under the laws of the State of California that the intormation provided above is We and correct.In addition,I am aware that falsification of this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to$25.000 per day,per violation or ad inis "'as up to S5,Coo per violation per day as described in Public Resources tratl penI Code eec6on 42962 —C J 1 3 1 S 5072 074 �� Driver's Name( rint) Driver's Signatu Date I ,. i 'J . . •.• • Program ' 469,4788 Pick.UpDelivery_ F]" D F Hauler Tire Program ID / Site Suffix Facility Telephone Number 1 DATE ❑ / ❑❑ / ❑❑ a e w 11Whole Tire Count Weight In Lbs. �.Cal IL Facility Business tp. .. ❑Volume Cubic Yds_ �Weight in Tons Blame/Address J City,Stateand-Zi. o Hauler Name _ U a IStamp or Label OK� ' Hauler Telephone Number Address Same as Hauler Initials 1 (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.- • • • Log Number •. • InformationProgram 4 6 9 4 7 8 8 -- B Pick Up- Delivery 1 +� $ 3 5 — ® j a ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ L11 °�' Facility Telephone Number Hauler Tire Program ID / Site Suffix DATE . ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ :i � wa a Whole Tire Count �Weight In Lbs. Tf1;;0 VlhQ�re-Reeyc11n� FaDiol Volume Cubic Yds. ` Weight in Tons Name/Addr s 11419101813151 ® 1 0 City,state` 'Awa(bcir ftid ' ..Hauler Name - • .�g�1 a Sacmme' nt®.CA Tri-C.P�FG�re Recycling.Div EOOHHWH o ,Stamp or Label OKHauler-Telephone Number Address Same as Hauler rDrnals.. . (NIA for I CE�RTIFY.THAT UNDER PENALTY OF PERJURY OF THE �" �> ,.�� ®,. - '" Whole Tires) LAWS OF THE STATE OFC ORN HAT THE } INFO TION PROVIDED AE4VE IqftE AND CORRECSite Suffix Comprehensive Trip Log Number T. i Q 46947,88 --:A / rmation Facility Tire r Pick Up DeliveryHgy -❑ �.❑ ❑ T115 ❑ ❑ o ❑ Hauler Tire Program ID / .Site Suffix acili Tel one Number DATE ❑❑ / ❑� - e w E Whole Tire Count [] Weight in Lbs. 0. 0 1 0 Volume Cubic Yds. Weight in Tons nei6a Gress Hauler Name I am,WIp .�y 3:�1 Tri-C MFG/Tire RecVding Div � UEOR 1' � J U - a ■ Address Same as Hatiler Hauler Telephone Number .• rnrtiars 916-37� 1700 (N/A for I CERTIFY THAT UNDER PENALTY NI PERJURYOFTHE r 1tlVEJVp Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.