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Recovery CA Comprehensive Trip Log and Receipts : Dept.of 1259,Resources adeno Recycling 12'-125 0002 � - P.O.Box 1259,Sacramento,CA 95812=1259 CaIR@C�CIe E Com rehensive Tri Number stere rcm;rom; 7 8 3 2 A i,! <'. G7Recyyg2Q9r7A,)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE By signing this CA Comprehensive Trip Log and Receipt,the signerts)request that the information provided on this form will be considered confidential,proprietary and trade secret In accordance with TIUe,14 CCR,Section 17061 at seq.,If a request Is made for disclosure of this Information,CalRecycle will contact the signer(a)of this form at theaddress and telephone number provided on this loan or recelpt Vehicle Information Truck Decal Number Hauler Address Fa rc►n,h o" Business NameO /U •�,i I,j _ S Address 3 7 3 C W of 2 03 © City,State and Zip he License Plate Number State • 1 on M PE � RE P R 0 Carrier ' I certify under penalty of perjury under the laws of the State of California that the information provided above is true and correct.In addition,I am aware that falsification of thisinformation mayresyft in w ension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to E 25,000 per day.per ve lmn of administrative penalties up to S5;DO per vi tion Per day as described in Public Resources _ Code section 42962- (y//./dJ � A1 ' ;` J� � r /� - Z7/ Z. Dri'ver's Name(print) Driver's Signature Date ProgramComprehensive Trip Log Number Load Information Facility Tire ;! L - 4 7 8 3'2..4 0 -- C.. Pick Up- Ll Delivery .IE000000- DL Facility Telephone Number' Hauler Tire Program ID' / Site Suffix DATE Dun DODD c w Whole Tire Count Weight. Lbs. a Fac►lify Business tt� F1 Volume Cubic Yds. E] Weight in Tons - Name/Address ' c :Hauler Name. City,State and Zip { 3 g Stamp or Label OEC Hauler Tele hone Number ■ Q Address Same as Hauler Initials p - (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE• - Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE .�'r"g' - -INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. q a 41783240 -- B' a Pick Up �. Delivery (D v Facility Telephone Number, _1 oC Hauler TireProgram ID / Site"Suffix DATE 4, U) 2 � 000 � a �= i ht in Lbs. c - w © Whole Tire Count E]We g y CIL Facility Business - r ` D. Q 9 j E] Volume Cubic Yds. El Weight in Tons tUante/Address ' �F o .Hauler.Name_ :City,State grid Zip _ Stamp or Label OK, 'Address Same as Hauler'., Hauler Telephone Number ■ mitiars (N/A for I.CERTIFY.THAT UNDER PENALTY OF PERJURY OF THE Q Whole Tires) OF THE STATE OF CALIFORNIA THAT THE •'��(J INFORMATION PROVIDED ABOVE IS TRUE ANDCORRECT Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix CL 47 8 3 2 4 0 -- A a Pick Up Delivery bilu ' Facility Telephone Number �' Hauler Tire Program ID / Site Suffix DATEOD / �� / � ff r ew E] Whole Tire Count Weight In Lbs. :,. a F °° `s'Gtcr sSSGq l ►�'ot'h lci , Volume Cubic Yds. Wei ht in Tons N��re s ro l I• Q g �y ` Gt.V CA S Hauler Name Cit 4aZ else�Ip. �. Sic %o•-► k U) a •- - Enu `Stamp or Label Oe6r' , a . W■ X 'X Address'Same as Hauler rnierars Hauler Telephone Number (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OFpTHE v ,1 ~� Whole Tires) TAWS OF THE STATE OF CALIFORNIA THAT THE M1,• .''�Q� 6' / INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.