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Dept,of Resources Recycling and Recovery CA Comprehensive Tip Log and Receipts 1000 P.O.Box 1259,Sacramento,CAg5812-1259 CBftCyclB jEjXjAjMjP-jLjEj III2 3 Comprehensive Trip Number c n."ryaeao�INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE ' 4860920 ' By signing N4 CA Compreh-I Trip Log and Recallthe slgnar(s)mquast that the Information provided on this tone will be conaldared confidential,proprietary and trade secret.In accordance with TIC.,14 CCR,Section 17041 at seq.,N a request Ia made for disclosure of this Informatlon,C•IRecycls will contact the eigrier(s)of this form at the address and tatephone number provided on this form or recalpt, Vehicle Information Business NHaulers N ame Address ,��,`�`� Truck Decal Number 73 Address 9Cit)4_ © 5 © ®. .` State and Zip Llcense Plate Number State I El ca l�� I eertey under penalty of perjury under the laws of the State of Callfornla(het the informallon provided above Is true and correct.In addition,I am aware that Ialslficatlon of this infamatlon may result h suspension,revocation,or denial of renewal of the Waste Tre Hauler Regbtrellon pursuant to Public Resources Code//142980 and may resuh In cM[penalties up to 5 25,00.1 per d .per vioIII or administrstly penalties up to per vl01I per day -described I.Public Resources code recti 4 O — _.,` 1 •a a 1— l q t)1 fLJ' 7 Driver' ams rint Driver' Si nature Date Comprehensive Trip . . Number Load Information Facility Tire Program 4860920 -- L' Pickup. . Delivery. ❑ ❑ ❑ ❑ ❑ ❑ ❑ j Facility Telephone Number Hauler Tire Program IQ ! Site Suffix cc DATE / �( w Ve Q ❑- ❑ ❑o ❑ ❑ ❑ ❑ Who Lin We ht In Lbs N j \ Fa lity Business of is ubic� a ht In To s. N- /Address. c Hauler Name ity, tate and Zip Stamp or Label OK Hauler Telephone Number ■ [:] Address Same as Hauler Initials (NIA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE 18 TRUE AND CORRECT Comprehensive • Log Number Load Information Facility Tire Program ID Site Suffix .a W, 860920 -- B Pick Up 'Delivery N 15® EN T DR I a Facility Telephone Number Haulr Tire Program ID / Site Suffix DATE a ®`Whole Tie Count ❑ Weight In Lbs. ar O Volume Cubic Yds. Weight In Tons l ' - c Hauler Name Ci�y, thtR a Zi �l � H uler Tel hone Number ■ CJ "`a"'ess Same as Hauler 1 nest/r 11. ( it (CERTIFY THAT UNDER PENALTY OF PERJURY THE 1y1 Wlloleole Tlre•) LAWS OF THE STATE OF CALIFOANUi THAT THE INFORMATION PROVIDED ABOVE 19 TRUE AND CORRECT. Comprehensive Trip Log Number Load Information F�acility Tire Program ID Site Suffix a 486-0920 " A "Pick Up Delivery: , © �- Facility Telephone Number tv Hauler Tire Program ID / Site Suffix DATE ©® j a© / �© _ � to Whole The Count ❑'Weight in Lbs. 1 F li Busines C .I�1 16. 1 O ' ®volume Cubic Yds. ❑ Weight In Tons. N, victJ �� 1 1 cHauler Name C t e a Zi y end Hauler Telephone umber ■ J�Abd&Cess Same as soler lnrfrau �+� (N/A for ICERTIFYTHAT UNDER PENALTY OFPERJURY OFTHE [2L8) /WS_ ` I }t' Whole Tires) IAWSOFTHESTATEOFCALIFORNU.THATTHE WS �j 1.7 INFORMATION PROVIDED ABOVE 15 TRUE AND CORRECT.