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TOIL Free 1-ov6-696-0600 / www.calrecycle.--.gov/Tires/ <br /> Dept,of Resources Recycling and Recovery <br /> CA Comprehensive Trip Log andRedeipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 <br /> GalRecycle E X A MP L E 1 2 3 Com rehensive Tri Number <br /> Cat oe2o7ng)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE.STAPLE OR DUPLICATE f 52242-98 <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 attendance with-F.tla,14 CCR,Section <br /> ~17041 at seq.,It a request is made for disclosure of this information,CeiRacycle will contact the signer(s)of this form at the address and telephone number provided on this form or receipt <br /> _., -hauler Address <br /> fuck Decal hurnber - <br /> t1tiSlileSS!'`�3file <br /> C�l U E i E AddrFBs9 city,State and Zip e- <br /> License Plate Number Stale -� <br /> E51L-1 L�E � ', 11 !n� L � —� Gamier n <br /> I certify under penalty of perjury under the laws o1 the State al California that the information provided above Is true and correct.In addition,1 am aware that falsiticallon of this information may result in suspension,rev inion,or denial of renewal of <br /> [he Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to 5 25.000 par day,per violation or administrative penalties up to$5.000 per violation per day as described in Public Resources <br /> code section 42962 ' <br /> d (� <br /> Driver's Nara (print) Dri Signature D e <br /> 47 <br /> • . • • . • . •• • Jx <br /> Suffii <br /> 5224298 CPick Up Delivery a e a <br /> o <br /> [11411 <br /> � Facility Telephone Number <br /> Hauer lire Program ID / SiteSuffixDATEa <br /> c _ DUE - PUDDEDE <br /> a [] Whoje Tie Count [ Weight in Lbs. <br /> Volume Cubic Yds:. Weight in Tons <br /> E <br /> - !�?tiler i�;3f11e _ <br /> _ .,.v x r6 <br /> r'1-.iCL @SS:�anne a`~-Hauler Initials -'-- <br /> _ ;Ni A.fcr I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> FWho!e Tiresj LAWS OF THE STATE OF CALIFORNIA THATTHE <br /> - INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> 522 <br /> 4 2 Pick Up. . Delivery P lE Ha <br /> Program IC) / Site Suffix nr rr <br /> Facility Telephone Number <br /> Hauler Tire Pro <br /> � g DATE0 kHHE <br /> a �1 Whole Tire Count Weight in Lbs. <br /> G 7 s I('j I ~ Volume Cubic Yds. Weight in,Tons <br /> � <br /> o Hauler Na/me _ <br /> [-!aulen-rTeleph�;-1e INLt f ,ger <br /> EEE0 Ez {iEE i i Ess Sallie as l'Hiner Initials <br /> ,N!A f Dr I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> l'w iote Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE NA/ <br /> FORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprdhe ve Trip Lb -.:,,-L08dI Worrhtitidn Facility-rire Program ID Site stiffix <br /> 1�Yy E <br /> 522429 ❑ PicdslJ� El <br /> ®eilvei EDDUD—EL11 <br /> Hauler Tire Program ID / Site Suffix <br /> Facility Telephone Number <br /> K� = 000 0000_ ooa <br /> n a Whole Tire Count E Weight to Lbs <br /> r Volume Cubic Ytjs 1(VelgrTfrr,Trus <br /> Hauler Naini <br /> Hacser Tele.�i1 r_ . r.,r.. ,. 4 fiC'_t ,w illi:as?t <il.= ni;irls <br /> a - - - - J?�/AYor I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br />