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Dept.o(•Reaourcee Rerlyoling ery'd Recovery
<br /> CA Comprehensive Trip Log and Receipts 10002 anX�2iu,tiaoremento,oA96612-y26g
<br /> Ca1Rg.G.�.018 X A M P L E11127 Com're',ensly Tri Number
<br /> d aiifa ai17,10)INSTRUCTI0NS ON BACK OF PART 2 DO NOT TAPE.STAPLE OR DUPLICATE
<br /> By signing Ihh.OACorripfohonllvo Trip Log and flooelpl,the slimer(e)request that ill Informeilgn provided on B nn will be considered oonl denlUl,proprlNary ond.lrads eeor@L In ocordmo►wl h Title,74 OR,8.olion
<br /> 17041 M a.q.,If❑requ..t le made for dlsolosura of thle(nlormetl❑n,O.,ReoyO.will contact Uu aleilglsJ olthltlomt sl the addrou epd talePhone number providetl on this form of r4040.
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<br /> ; Cg }• e; 5 Hauler Address
<br /> E Business Name Nsr ��.
<br /> Address
<br /> City,Stag and Zip
<br /> Common
<br /> r' Carrier
<br /> ^I aorilfll pddsrpenellyolpet[uryundglholgvn of Uta 6latli of QaOlornlathal,tholnformo8on pravlded abovi tri correct.in addflpd.lam car.Ihal falsification of Ws lnformalian may reiul(Ineusponslon,avocation,or denial of renewal of
<br /> 'Iha.Waste
<br /> T.N►dbr fbplslrplton pmsuanl to pWllo Resouicu Dodo�eolfon/1860 end mry resuil In civil penalties up to#48,000 per day,porbn or'adminriUalivo penslll$sup io 45.000 pef vbblIon por d y'u8esaibed In Pubilo Rasouron
<br /> Code aagggn
<br /> Driver's Name(Print) Driver's;Signature cz.'�;r �— e
<br /> 3
<br /> Comptehensive Trip Log Number : Load friforifnation Facility.*Tire Program lU
<br /> �I �
<br /> �11
<br /> Site
<br /> 6054569 i Pick U1iI
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<br /> iS Hauler Tire Program ID '/ Slte Saffix' �el.�p�}gn 'N{ile ;
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<br /> � F:arility Business j I• ,
<br /> Name/Addroiis.
<br /> q r Hauler <Frd4c:°V�., •2;-7, , GitY+ �il�
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<br /> Hauler Telephone m is- ? .,,1 n ( ! ❑ Address sam�as Hater rr re
<br /> (CERTIFY THAT UNDER P9114TYI6-PERJURY.017111i8
<br /> Y a LAWS OFTHl DTATl OF GALIFORNIA THAT TH a }
<br /> I i•+ ;Y`:i; vt ,'i_ p.�iNuk s' ` rfi.;.,' - ';*' .INFORMATIbN PROVIDEDAIOV!)BTRU AND ORRCOT,, ° r
<br /> Comprehensive Teip Log Number Load Information Facility Tire Program ID Site Suff i
<br /> 6054
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<br /> F�t a Hauler Tire ProgramM ;/ Site�Sufflx;(,, : �r �]'J� , I yR! ;Faolli y T�le�phor?�:J�It�tYt et; t
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<br /> MAN# y Buslness
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<br /> Hauler Name64Qj.fA 101
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<br /> Hauler Telephone Number ( i as-Hat ler fill Ks
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<br /> t,�:•_. ❑ Address Sam13
<br /> ss� ( } 10ERTIFY THAT UNDER PENAtTY�OFPERJURY
<br /> STATFTIIE
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<br /> ,ry �j 't ❑J; •r" - �t LAWS OF THE E OP:C)ALIFO 'I1ATTNy]J',
<br /> "1 FQ� �f ?rd•;>. "`t;r " F,- = .:c .,INF.ORMATIONPROVIDEDABOVL!S:TRUEANDOORRECT,';
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