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Toll Free 1-666-896-0600- www.caIrecycle.ua.gov/`tires/ <br /> Oa Dept.of Resources Recycling and Recovery <br /> CA Comprehensive Trip Log and Receipts 10002 P.D.Box 1259,Sacramento,CA 958,2-1259 <br /> Calftcycle E x A M P L E 1 2 3 Com rehensive Tri Number <br /> ' 5224206 <br /> �zt•ar CarAenfa _ <br /> c�Reyieaxtpnu�INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE <br /> By signing this CA Comprehensive Trip Log and Receipt,the signer(s)request that the Information provided on this form will be considered confidential,proprietary and trade secret In accordance with Title 14 CCR,Section <br /> 17041 et seq.,It a request is made for disclosure of this infomation,CalRecycle will contact the signer(s)of this form at the address and telephone number provided on this form or receipt. <br /> _ Id<etfiii}efifor_mattan^ <br /> 1n k Decal N'-urfter Nadler Address F — <br /> Business Name Wholesale Equipment of Fresno <br /> _ F <br /> Ll ®' Address dba Wholesale Industrial Parts <br /> City, State arld Zip <br /> License PPia(neNumber State 536 .Display Way <br /> L _.1 1 ❑ �� ❑ c r ;"n I Sacramento, CA 95838 _ <br /> .e mty under penalty of perjury under[he 11-of the State of Caldomia that the Intern provided above is I—u -i.f canect.In addition,I am aware that Izlsi anon of This information y result In suspension,revocation,or denial of 2newal of <br /> the Waste Tire Hauler R intra:ion pursuant to Puhlic RFsounces Code section a296 y result in civil penalties up to S 25,000 per day,per violati ora i Istrativa penalties W ,000 per violaIIon Per as tlescn tl in Public Resoumes <br /> Code section 42962 t <br /> Drivers Name(print) Driv r s i atur ate <br /> 15Ti 7, �7771 771 MMM . . 1 . . . <br /> 5224206 Pick Up ❑ Delivery ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> U <br /> Hauler Tire Program If? / Site Suffix4 Facility Telephone Number <br /> DATE ❑❑ ❑❑_ fl <br /> Lu E] Weig.Whole Tire Count tit in Lbs_ rn ❑❑❑ ❑ ❑ ❑ ❑ <br /> ❑ <br /> ❑ Volume Cubic-Yds. El Weight in Tons <br /> q <br /> E riauler Narrie =E <br /> e , <br /> u7 � <br /> Hauler Teierl i'.t;r;. ._- <br /> Initials <br /> (N/A for 1 CERTIFY THAT UNDER PENALTY OF PERJURYOF THE <br /> L'J:-inle Tire) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> --- -- INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT <br /> R 5 2 2 4 2 0 J13 <br /> ( Pick Up Delivery <br /> 0 Hauler Tire Program ID / Site Suffix ` Facility Telephone Number <br /> DATE OE <br /> , I E <br /> E [1]2� <br /> c _® � l�l�❑® � ❑ ❑ ❑ ❑ <br /> LU ❑ <br /> a Whole Tire Count ❑ WeCgfTtin Lbs: <br /> 1411 31S � ,0C F ❑ Volume Cubic Yds. ❑ Weight in Tons <br /> F <br /> E5 -taul„rN me r t` CJy <br /> -AAA' <br /> Hauler Telephongmq hiu-11-tike n�� MEE I A ddr.°.S8 S:atne as HaL.tfer <br /> _ �� � ��� RT Initials <br /> (N/A fo I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tiros) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> 5224206 A �t�klp Deilvery ❑ ❑ ❑ ❑ ❑ ❑ ❑�❑ ❑ <br /> _ Site Suffix <br /> Hauler Tire Program ID / T ( '� Facility Telephone Number <br /> sx` <br /> d Whole Tire Count Weight in Lbs. <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> E <br /> 1011 1I'S t 3 1 Volume Cubic Yds. ❑Weight in Tons _ <br /> aider#dame � - <br /> Aclldr_.!_Same as Hauler <br /> Hauler PL:rTs` <br /> _.. <br /> "- - - M/A'far. _ I CERTIFYTHAT UNDER PENALTY OF PERJURY OF THE <br />