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' Dept:of Reepuro9e Recycling and Recovery
<br /> CA Comprehensive Trip Log`and- eceip'ts 10002 po,8ox1268,Sacramento,0A86012-12G9
<br /> CajBC Cjg X A M P 'L E' 1 2 3 i _ Com rehensive Tri Number
<br /> c'uf'"aaaaipiiglN$TRUCTION$ON BACK OF PART 2 DO.NOT APE S Ah R DUf?L CATS
<br /> � Ey signing this CA Oomprohan•tve Trip lop and Recolpl,III aluner(■)request that the Inform■Uorl provided a,Ihle farm will a oaneldmtl aenlidenllel,praprlelery end Rede eesrol.In oaoordenoo wINThIa,14 CCR,Ee6tlon
<br /> 17041•Laeq.,If a r8queal le m■de for dbalawro of Ihle loformallon,CalRaayolo will contest the 4lgnerlQ o(J a loan nl trio ddran and lelophone numbarprovltlotl on Ihla form or reoolp6
<br /> Truck Deor111N trilirer�l a`:;` hlaulor Address ; y /
<br /> (j (� r Business Name
<br /> LTJ ^ ❑ I '❑ ❑ L�?J AddrA�st��nl�t
<br /> I IGense Plfate,Number State City,State acid Zip
<br /> ❑� � �❑ 0-k
<br /> CN
<br /> N ® LTI 9 � Carrier I k a�
<br /> I dedlyuhderpendty of porJury under the laws of Iha alete of Collforda trial Wo Inlormallon provided allow Is Into d couool.In 0.ddlllon,I am aware That lots oatlon of title Information may result In wspenslon.rovooillp�,of4enlel of lonew I of
<br /> the Walt•Ne if Rogge gallon pursuant to Public Resources Code4ullon 42060 and may result In olvif penaido1 up to 526,000 per day,pervro ion or min lalrallJo Do We up to$5.000 por vlo(alionDor dayeedt."bod In Pullk Rim roes
<br /> Code tail) n 4206
<br /> Driver's Name(print) Driver's Signature Date
<br /> 1 e e e • • 1 Program 1 A
<br /> .- Site Suffix
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<br /> 57'58007 �- C °r�❑ kck Ula t D�Iive►y ❑ (� -(�
<br /> Mauler Tire Program ID / $Its Suffix i / ❑ % fac.111ty Telephone-Number
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<br /> I W I VVH.ioTiteOount PIePub Lbsf)
<br /> t IL _ Fodlity L7ut3inesc
<br /> �. olume'�f Ic yds. ❑ Weiyht"Ih T s A1PHTt::/llridre�5
<br /> ;ilato al)(1 zij)
<br /> Hauler Nam
<br /> C I bitty l.ui:rcalOR
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<br /> ■ Address,acne as Hauler
<br /> ;�� NaularTolephone umbar p{s nrtra+
<br /> If ! - l('l/�s�tel'h�7; I CERTIFY THAT UNDER PENALTY 00 PE({JURY OF THE
<br /> ;,•+ /_, ---Who(p 71r08i TAWS OF THE STATE OF CALIFORNIA THATTHE
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<br /> `•t ,t♦- INFORNiAT ION PROVIDED ABOVE 15 TRUE AND CORRECT,
<br /> 5' • . e s . e • • • • M
<br /> -k�'-171 i, ;� .,_ :.. .,
<br /> 97
<br /> 58007 I.I. �pickU�l L Deliver "'" -y iED OF
<br /> .HaulerThe Program ID 1 Site Suffix ; o
<br /> � i Faeiilty Teleph�orte.Number
<br /> F 101
<br /> flp
<br /> ": w WI1u1e Giro CoUnYT,Wc�Ic ht in Lbs: ©�® ® 92) 9 F
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<br /> e p ❑'Volume;Cunlc Yds. ❑ Welght In Tons ►�l(ulksi
<br /> E; .1^lauler Name
<br /> Hauler Telephone Number Ie Addrods'Samo ns H�udcr' mma+s
<br /> ICEIiTiFYHE STATE
<br /> EOF ULIORNI PERJURY Or THE
<br /> �• r� _ .:Wh❑Io AWS OF THE 9TATE OF CALIFORNIA THAT THE
<br /> ! - INFORMATIOtIPROVIpEDAa04'EIg.-I l EANC,CORRECT
<br /> C -npi-ehensive Trip Log Nu.rnber' Load Information Facility Tire
<br /> Site Suffix
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<br /> ' 5 7 5 8-a a 74► s ❑ °4 _=�,, l' � � ', f ❑-❑
<br /> 4Ti�F _ F6611I}��'el6phone,Number
<br /> Hauler Tire Program.10 / Site SVITI f
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<br /> o ire ,,i1a ;,, -, i' t` r ;,1,,:;.❑ `.❑
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<br /> M»iilei'Tam$` iLy,[^�{►j` jJttr:('y>t,c Cj -
<br /> C) =• © ;
<br /> Hauler Telephone Numbc,r
<br /> ❑��..��t��t,", fn tab
<br /> t�, f , g.+ ,.,^ �.d .+ .v iLlf qY . _ �PA.N�4T'h0}'AER>IURYOFTHE� ) ..-v
<br /> y '/� ) �S 1� 0 �'8., Zf�!: 4ORyf�TNyT,TNE. •/
<br /> _, ;; U�i. 1 60.'.B V�7EA U6�AtID;CORRECT, 1
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