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Dept,of Resouroes Reoyoling and Raoovery <br /> CA Comprehensive Trip. Log and Receipts 10002 RO.Pox 12tg,Sacramento,CADS812-1288 <br /> CfljRjpyCjB X A M P l E 1 3 = oom rehenslve Tri Number <br /> 6falaafOaNa r ' ,..`. 7 5 7 - <br /> carAetrr�2wti<roIINSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE ' <br /> r ,0y alanfng Ihis CA 0omprohendvo Tdp Lou end Rvnlp1,.tho elgnor(a)r.quo.t Ulel tha Inlomutlon provldod on this form YJ11 ba condderod confidential,proprietary pnd trpdo oaaraL In e000Monoe with TItIo,7M1 CCR,3ooHon <br /> -17041 of arq.,U arvgdvsl le made fordleoloanr*of thla lnloraintlon,OnlRvayolo Will conlooI thoafanorly)of lilts form at the address and to]ephone number pravlUyq on ltfAdaaak(Oran rob lnlpt. <br /> s t• r a 16 <br /> TruOk:v#oat Nu17iber Hauler Address }� <br /> C�usiness Nance I ✓ r7 <br /> k=u' lw J _IJ LJ l Aciciross �7''7 <br /> City,State and Zip <br /> License Plute NUIpbQr Stara ----1 <br /> u Common � <br /> Carrier _J <br /> I conlfy under penally of psrIM under the Imus of IAB Stale.of Onllfornia That the Inlormllon provldvd above Is two end eorreol.In addllfon,I am awaro that folsiRaetlon of 1hI ornfellon may resvll In smpenalon,rovoaalign,or�denlel of renewaf of <br /> the Wasiv The Haulu Reglsballon puntuant td.Publle Rosovrcee Code 2110n,12060 and mayrasult In cMlponalllos upto$26,000 par de r ISI ton Or atlminlslralNo onelllO up to 56,000 par ola(Ion per day m de Led In Pdhlld Rasourco <br /> Code sec /2062 f <br /> Driver's ams(print) Driver's Signature Date <br /> a . .- • • • <br /> 5757704 ..o (� t� ` : r ' ' ix <br /> p'e�iuery <br /> pC�� ailit� 0000a-ac <br /> ='v Hauler Tire Program ID / Site Suffix ''=Nz, ' :F, cility ephone Number <br /> � oa � <br /> i�il wr(]l hole CotPub ; Y�oi kin}rber <br /> 4Q of eC}iblolYds ' Wel ht ImTonsr 1�!rarite/t cich 5,r <br /> o. Hauler Namo ) l <br /> i <br /> Haulor Talophono Number <br /> Address Sarna r s Hauler roofers <br /> ' (N/(s 10t' IGERTIFYTHAT UNDER PENALTY OF.PMURYOFTHr <br /> 1,4�1; Wh19J�.(fu¢l {,INFORMATION PROVIO ppROVER9T THE <br /> TRUEAAN D CORRECT <br /> s1Tj 1 • a • 1 • 1 a -1.b Site Suffix <br /> 5 7 5 7 7 0 4 4 pick t1p f i Delivery ® ® � <br /> ODE f r <br /> a' Hauler Tire Program ID / Site SuffIx � I :Facility Telephone Number <br /> :a R- R-H-0�R 0 �C <br /> w ❑ Whore Tire Q¢urif p w�tgnnln gas, <br /> ILI 0161011 <br /> �. Q VplumetOubJc Y�� Wv,gh#1n Tolls{ Nrin 1 Garirll t 'p <br /> Hauler Name <br /> -14 <br /> Hauler Telophone Number �, dressSame as Hauler fflg, <br /> x�/�' 3-1 <br /> -7yI CERTIFYTHATUNDER PENALTY OF PERJURY OP THE <br /> j� / WNOItl TIr0�9� LAWS OFTHE STATE OF CAUFORMA THAT THE <br /> -_ INFURIAATION PROVIDED AEOVE 19 TRUE AND CORRECTRM . <br /> s <br /> Comprehensive • to •.• Information Program11 Site Suffix I <br /> 5- 157704' r1 H n l ♦y� 5 �v �' qt <br /> Tire Program ID / Site Suffix s - 6ac7 . <br /> lllty Teletphone'NUmiier <br /> r a (Q o An <br /> 2 <br /> It <br /> _i <br /> 1 <br /> HavjQr'NaifieCIO <br /> •� , I''�•RSV�J <br /> H:�ulel'Telttphone`Ntimbar r ! � �� Address Barrie as Ilat(IoJ. Initials <br /> 117 T-- �• t. 1DRRTIP <br /> Y TIfAT I)NOER PfiJIALTYIOF P6RrIURY OF.THE <br /> - L THR.STATEOF.CALIFORNIA THAT THE. <br /> WFORHAII0 PROVIDEOAOOVE 1e TRUE'AND.00RREOT. <br />