COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

�• -�)'' T•. - Dept of Resources Recycling and Recovery CA Comprehensive:Trip Lo.g-'afid:Receipts 10002 P.6.Box Comprehensive TripNumber CalRec cle: E x A nn P E z 3 �y RDUPLICATE �t554584 CaIB zm n INSTRUCTIONS ON BACK OF PART 2 ADO NOT TAPE,,STAPLE O _ m'� n � By signing this CA Comprehensive Trip Lound Receipt,the si9ner(5)request that the information provided on this lone will be considered confidential,proprietary and trade secret.In accordance with Title,10 CCR,Section - lTD41 at seq:,N a request Is made for disclosure of this Information,CalRecycle will contact the signer(s)of this form at the address end telephone number provided on this form or recaipL Vehicle Information j. Truck Decal Number Hauler Address a'1rV\61r�n i1 - Business Name -© 'll Address 3'73Q : A)r w ; 1Soo L'VQ J City; State and Zip i License Plate Number State s�'G `}C v� C A 9 S Z a s ® a a D a Carrier on 1— 5 . 1 certify undei penalty of perjury under the laws of the State of California that the irifonnalion provided above is true and correct In addition,I am aware that talsification of this information may result in suspension.revocation,a denial of renewal of the Waste.Tire Hauler Registration pursuant to Public Resources Code section 429W and may result in civil penalties up to$25,000 per day,per violation or edminislratNoe penakies to E per violation per day as described in PubliAsources , Coda section 42962 Driver's Name(print) river's Signature Date ,. Comprehensive .. Program a Suff ix 4.5;5:4158 4 -- C D Pick Up ❑ Delivery ❑ ❑ ❑ E00 ❑-❑ ❑ { Hauler Tire Program ID / -Site Suffix DATE Facility Telephone Number. ❑❑ ❑❑ ❑❑ ` wa ❑ Whole Tire Count ❑Weight in Lbs. .toRaetlity Business f .tom ❑ Volume Cubic Yds. ❑ Weight in Tons Name/Address c Hauler Name City,Stale'and Zip Lo Stamp or Label OK s ■ ❑ Address Same as Hauler Initials rHa7ule7lephone Number t (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE ( INFORMATION PROVIDED'ABOVE IS TRUE AND CORRECT - m�l • • • •e •' • • Information - •e 1• a 45_5.45184 ' -:-B. - ' Pick Up Delivery 0 PER R 9 ' R R ❑ 0 Hauler.Tiee Program ID /. Site Suffix Facility Telephone Number.` cc DATE �� / DD / DD na, on P60000a W ❑ Whole Tire Count ❑ Weight in Lbs. 'Facility.':Bu'siness ElVolume Cubic Yds: E] Weight in Tons "Name/Address o ,Hauler Name _. Pity,State and Zip: r J � . V c l Q O x. X Stamp pr Label 01K.. Hauler,.Telephone Number ■ Address Sarne.as-Hauler" m;r;a,a -- - - (N/A for 'I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE. • /� - Whole Tires) `-LS OF THE STATE OF,CALIFORNIA THAT THE 7 / 'INFAWORMATION PROVIDED ABOVE IS TRUE AND CORRECT Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix a 4554584 Pick up Ll Delivery a a R'.N 9-H 3 - Hauler Tire Program ID -/ Site Suffix Facility Yelephone Number i DATEDD / ©� / DD c .. 5 R w ® Whole Tire Count ❑ Weight In Lbs. co a F Is, si Gf�l��.o'etit q L� - ❑ter}��55OR RR y. >_ 11010 El Volume Cubic Yds. Weight in Tons Name/Address f- C W'.. E cif A6;Lana yip. ; o Hauler Name 'T L f Z 13 ' U A n Dn Yr gg Stamp or Labef:& E 7 a ■ X Addres_._' ' as Hauler.° rn;r;ar 'Hauler Telephone Number r (N/A for I.CERTIFY THAT UNDER PENALTY OF PERJURY OF THE ',.. Whole Tires) LAWS OF THESTATE OF CALIFORNIA TNAT E �f7 / (J INFORMATION pZVI DED ABOVE 7H IS TRUE AND CORRECT,-- J-