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-- - --- ---v - -- - i <br /> 10002 P.O.CA Comprehensive Trip Log and Receipts Dept of Resources Recycling and R2-125 <br /> Box 1259,Sacramento,CA 95812—1259 <br /> CalRec cle <br /> E X A M P L E 1 2 3 Comprehensive Tri Number <br /> state ofcaft Y 4661965 <br /> ears.�T�/f0INSTRUCTIONS'ONCA Comprilhensiwe Trip Log and eBACKlpt.the eOF PART 2r(s)req�t that the nfaDO NOT TAPE,STAPLE rmation provided on this fam will be dORdDUPLICATEBy entiel,proprietary and bade aocnsL lnaccordance with Tl"e,14CCR.Section j <br /> 17041 at seq.,thisI/a request is made for disclosure of this Information,CalRecycle will contact the signer(s)of this form et the address and telephone number provided on this form or receipt. <br /> Vehicle Information Hauler Address F <br /> Truck Decal Number INLAND INDUSTRIAL <br /> Business Name <br /> ® � ® Address TIRE NORTH, INC. <br /> License Plate Number State City,State and Zip 30900 San Antonio St. <br /> a ® � ❑ Hayward,CA 94544 <br /> 5 Common (510)429-2999 <br /> Carrier <br /> I certify under penalty of perjury under the laws of the State of California that the information provided above is Ime and correct.In addition,I am aware that falsification of this information may result in suspension,revocation,.W denlal of el <br /> the Waste Tire Hauler Registration ursuan1 to Public u e sect 42960 and+meymuh in civil penalUes upato$25,000 per dWp violation pr administrative Iles up 1 55,000 per violation per day e,disc bill a rtes <br /> Codas esr / S t Y. Z �n 4 /� / <br /> a Driver's Name(print) Driver's Signature a <br /> Comprehensive Trip .. Number Load Information Facility Tire Program <br /> 4661965 -- C Pick Up Delivery <br /> 0b� <br /> Facility Telephone Number <br /> Hauler Tire Program ID %; Site Suffix DATE <br /> a M-Whole Tire Count [I Weight in Lbs. <br /> Facility BIMPAND INDUSTRIAL <br /> l � / Volume Cubic Yds. �Weight in Tons Name/AddrTIRE NORTH,INC. <br /> o Hauler Name. City,State at Flu i <br /> 30900 San Antonio St. <br /> ci 7)l�� Stamp or LaHayward,CA 94544 <br /> a /naiars <br /> ■ '[Address S4Sit4�ls1fZ9,t2A89 <br /> Hauler Telephone Number <br /> (N/A for J CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE O <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.. l•�'�� <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suff ix <br /> IJ <br /> a 46619 -- .6 a P ck Up 11Delivery <br /> 65 � R9. <br /> Facility Telephone Number . <br /> ,+a <br /> Hryuler Tire.Program ID / Site Suffix DATE �� / ©� / a©• <br /> E 1f wa. M:Whole Tire Count [:] Weight in Lbs. � <br /> Fa ility Business <br /> ❑volume Cubic Yds. Weight in Tons I`V� _`�0 �/�/•���`� <br /> E ;Hauler Name Ci <br /> tt? zi.. <br /> v NLr}c��l7 I't:'�-r Sta : �, j }Q� 9? 3 0 . <br /> a <br /> Hauler Telephone Number DODO ■ Q Adtl"cess Sa..a as Hauler rnmars <br /> � (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE''. <br /> Whole Tire S) tAWS OF THE STATE OF CALIFORNIA THAT THE e <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> .. • • • • • • - • • • • •s 1 ._ <br /> 4 6 619 6 5 -- /�► Pick up :: Delivery. <br /> .iv <br /> . o o aeac� <br /> Facility Telephone Number <br /> / • <br /> Hauler Tire Program 1D Site Suffix r <br /> cc DATE <br /> wa ®Whole Tire Count E] Weight in Lbs. <br /> Fac lity Business <br /> / L] Volume Cubic Yds. Weight in Tons Na <br /> •. <br /> E miry ,S atTe d dip <br /> Hauler Name X <br /> �UvH S- CL 30 <br /> U / /LJL1'9��� / J �r a Stamlr�a�• :i r: Tc.n� 9 SU'�-C� <br /> Hauler Telephone Number =� ■ 0 Address Same as Hauler Initials <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> L I <br /> Whole Tires). IMOF THS STATE CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECL� <br />