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Se D. 1 (. 10 14 11 :4/Aid ts, on I i re No. 66H N. 1/ <br /> Toll Free 1-u66-896-0600/ www.calrecycle.ed.gov/Tires/ <br /> DepOa CA Comprehensive Trip Log and Receipts o 1250.Resor�sRn��edW812-nd vary <br /> 10002 P.O.a.o.Box t2Se•sscranento,CA osatz-126e <br /> X A M P !. E 1 2 3 Comprehensive Tri Number <br /> 9INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, DUPLICATE 4855599 <br /> BY 36V*M Vft CA CoffWO t N•Mp Loy m.d *—M I-Weel"Ow e$ormellar wotld+d oe 1Ah lout wS bet: Waved—Rdw IpL wow+derr and VyM sewn&In aecoraance RIIh TAI.to nen.Seam <br /> non el•eC,We reau=m fnaua for ebao m of U!a/arm•UwL Gag%w-b wR1 o t•otrhw Orr lel d 1"$9—"do•ddree.wW"I.Ph•-rvn b•. .v.:d.d t>n Ui•arm w rat.Vt <br /> I h Hauler Address aryl/] ''r11U� <br /> Truck ocal Number <br /> Business Name <br /> _ t� 0,0 Address ,\ ( <br /> ® Ciry,State and Zip 0 <br /> IJcense late Number State <br /> ® � MElCar ieron LS�W tN\ V i ' — 20,Fp <br /> 1 canT,under pon■•y of penury +h.I;,of de lMl UW WtYrnOW wa.+azd aetnw b Mra and carrbCUnadcw"L am a(INM Wa•la Tk.Na1or to Pubo ■16". &2V60 tvd mtqne++R n ta.J pe+dlw up la S 25, IRv pina•ks up 1p 76,pyp n Puuc F:Godoveaon&2862 Driver Nam rin ver's Signature e <br /> Comprehensive Trip •. Number Load Information Facility Tire Programr Site Suffix <br /> _ <br /> 4855599 - C.' Pick Up Delivery — <br /> m Facility Telephone Kumber <br /> Hauler Tire Program ID / Site Suffix HATE <br /> YlRtofe Trce Gount �WeighY in U. <br /> � �:'sig; ;'- .' �• <br /> c s / ❑Volume Cubic Yds. ❑Welght In Tons j.• ;;:';r =.; <br /> E auier Name <br /> fa owa rAC <br /> H I r ephon Number ■ (�Address Same as Hauler <br /> OVA for I THAT UNDER PENALTY OF PERJURY OF THE <br /> whole rwMI LAWS OF THE STATE CF CAIiORMA THAT THE <br /> p1FO!m6ppN PA- - ABOVE IS TRUE ANO CORREM: <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suff ix <br /> Fa6ility.Telephone Number - <br /> Hauler Tire Program ID / Site Suffix f <br /> _ HUE-a0 �o� e❑ <br /> L _ _ _. ..._.__. ... <br /> Hauler Wme <br /> ' �� ❑` r`�`��, � <br /> I'layl�r cic hur c Ru:r: er <br /> / I CESiTIFY THAI UNDI9i PEr1ALTYOF PCR.IURY OF THE <br /> �f� ,;.ea!rtsl3 ab stnnc;y Lit't ly�cr313-.^ya^.r.QV r:;�. + <br /> J LAWS of 7,1TATE DF CALIF0RMA THATTHE ti <br /> S�1 `•T`r.,l'"r+"! T ;+� INFORM" M PROVIDED ABOVE 18 TRITE AND CORRECT I l l <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 1 <br /> 4855599 -- A k Up Delivery <br /> Hauler Tire Program ID / Site Suffix r-_rasa `'` E'. Facility Telephone Number <br /> DATE fir <br /> riorpr; 77 <br /> r / ! I-II / b d:%7:1G?& car•::-4 Orr:^ rr•�I. ;C R.y;, ,; <br /> Volume Cubic Yda❑Wefght In Toric <br /> E I u(erNamo <br /> - /1nq r/ e[�Iy'one'r 1�,`,r6e'r ! _— —_ ❑ Address 58nte as HaulPr� <br /> /` G1 1 I�I+ n. 1 for IGERTF/TVR UNDER PENALTYOFPERJURY OFTNE <br />