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02 Dept.of Resources Rocycling and Rocovery <br /> CA Comprehensive Trip Log andrReceipts 10002 P.O.Box 1259,Sacramento,CA W12-1250 <br /> GalgeCyCle EXAM •P L E 1 2 3 <br /> ComprehensiveTriNumber <br /> srati.cr C.cran+a <br /> ca»rnaaa�nWINSTRUCTIONS ON BACK OF PART 2 DO NOT.TAPE,STAPLE OR DUP�CATE1- - . 4848481 <br /> By Opning this CA Cemprehnsln Tdp Log sad Receipt,do signed#)request that tM 4rformatlon pruAdod cr this forth will be Con•Idwvd coafltl•nUd,proprlNtry end trod•secret b ecoord—w!th TMS.,to CCR,Rection <br /> 17 <br /> st seg,tf a r•gueat Is mads for Mscbuwe of this Irdorm.Von,CsIRe ycN w01 c tsct!1+•slgnerisl 01 the form at the address and tefephon•n mlosr provided on this form 0r redslpt - <br /> Vehicle Information <br /> Truck Decal Number Hauler Address <br /> D <br /> Business Name �rulinc,D D D D D D Address3P�N, I1So') L.JU <br /> City,State and Zip <br /> License Plate Number State G <br /> DDDDDDD F111 � Carrier LLL Common ����� CA . I S2Q5 <br /> I.,..-.ty—w ponelfy d P-r"order the Iowa of tF•Sfat•of C.ft,la that mo Irf aflon pmvwed sbpve If Ime end correct.In addition,I am swan Ihat!2!.M—tM of fNa klla ,trop may—110,at4Parslon,revoealtln,a a.nld d rawal d <br /> a*waste res Halder HaWSIMLkOn pcaauant to Public Roae m Code t•dts 42990 and may resvT In ave penalios up Io S 25,000 pa day,per V;Natlan or • vwlat-per by as de IbW In Public Ros " <br /> Cods a-V-42 ,3,V-)U" r <br /> �' 'JP c�1�S <br /> Driver's Name d!] Driver's Si na urs 1 Date / <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> C Pick. Up. Delivery,484848 <br /> 41 Hauler Tire Program ID Y'-.•Site Suffix Facility Telephone Number <br /> DATE ME / <br /> oo�- Hao o <br /> m a 19rWhole.Tire Count Weight In Lbs. <br /> Facility Business <br /> w U D Volume Cublc Yds, Weight in Tons Name/Address <br /> o Hauler Name City,State and Zip <br /> Sta p or Label OK <br /> Hauler Telephone Number ■ FAddress Same as Hauler throats —J <br /> 2 � ` <br /> (N/A ole for I CERTIFY THAT UNDER PENALTY NI PERJURY THE THE <br /> (tY_ VYCO,� Whole Ti,") LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> MORMATION PROVIDED ABOVE A TRUE AND CORMCC V <br /> Comprehensive • Log Nump •- • • a • - Program <br /> Q <br /> 4848481 +- B D Pick Up Delivery - <br /> DDDDD DDD <br /> Hauler Tire Program ID I Site Suffix Facility Telephone Number <br /> � r I DATE DD DD DD <br /> DDD- DDDDDDD <br /> co aw Whole Tire Count D Weight in Lbs. <br /> Facility Business <br /> :I I Volume Cubic Yds. ElWeight in Tons Name/Address <br /> o Hauler Name 'City, State and Zip <br /> Q Q Stamp or Label OK <br /> Hauler-Telephone Number- ■ D 'Address Same as Hauler. fn rra; �. <br /> (N.fA for I CERTIFY THAT UNDER PENALTY Or PERJURY OF THE <br /> Wholo Tiros) LAWS OF THE STATE OF CAUFORNU THAT THE <br /> WORMATION PROVIDED ABOVE IB TRUE AND CORRECT. <br /> Comprehensive Trip •• Number • • InformationProgram <br /> 4 8 4 8 4 81 -- A Pick Up Delivery F a ? © a N-0 <br /> to Hauler Tire Program ID / Site Suffix Facflity.Tele hone Number <br /> � g DATE as � � as p . <br /> IM <br /> y DDo-as © o © DD <br /> Lu ©Whole Tire Count Weight In Lbs. <br /> z BL <br /> 4 �� �� Volume Cubic Yds. Weight in Tons �t�/!tdd+T` `eS h <br /> o �uler NameAn <br /> jHauler Telephone/Number ■ �'Address Same as Hauler 1rt;r erg <br /> (NIA olo it I WS OF THAT UNDERPENALTY CALIFORNIAPERJURY OF THE <br /> Wh010 Tires) LAWS OF THE STATE OF CALIFNITHAT THE <br /> INFORMATION PROVIDED A80VE 15 TRUE AND CORRECT. <br />