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Toll Free 1-u66-896-0600 / www.calrecycle.ua.gov/Tires/ Dept.of Resources Recycling and Recovery CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 Cajftycle E X A M P I L I E 1 2T3] Comprehensive TriNumber zai�no;INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE 5545923 Ely signing this CA Comprehensive Trip Log and Receipt,the signer(sj-quest that the information provided on this form will be considered confidential,proprietary and trade secret-In accordance with Title,14 CCR,Section 17041 at seq.,if o request is matlo for disclosure of this information,CalRecycle will contact the signerls)of this form at the address and telephone numbor provided on this form or receipt. Truck Decal Number Hauler Address l L,,,;�1 ac.e�rl��1$�P(" S ©N i ' � � Business Name �__rr Address �3� �. �011�1AGe, City, state and zips qS3,3� License Plate Number State ® ® a a o ® o aIt 1:1Carrier certify under penalty of perjury under the laws of the Slate of Calitomia lhnl the riforrnalion pvvided above,s true and correct.In addition.I—aware that falsitication of this information may result in suspension,revocation.or denial of renawaf of the Waste Tim Hauler Regigimion pursuant to Public Resources Code sect on 42960 and may rowll in civil penalties up to S 25,000 per day,per vi boon or edn inisua:iv.penaltfos up t 55.000 per'.vloI lion per day as described in Public Resources Code section 42962 I - n Le.ot�ra Driver's Name(print) Driver's Signature Date h1l . . Program. x 5545923 -- L' Pick Up Delivery Hauler Tire Program ID / Site Suffix Facility Telephone Number DATE N aoo - 00000aa a Whole Tire Count ❑.Welght:*ht:* .,Lbs. y I I I Volume'Cl1biC.-YdS. ❑.Weight in Tons E Hauler Name - - - - V) U a Hauler Telephone Number ODDDD-Do F' ] Address Same as Hauler --I Initials (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tlres) LAWS OF THE STATEOF CALIFORNIATHAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT, Ll 5 5 45923 -- B ❑ Pick Up Delivery o a a a a a-a ►t U Hauler Tire Program ID / Site Suffix Facility Telephone Number DATE m d Whole Tire Count Weight_imLbs. aao � 0000aoc ~ Volume Cubic Yds; Weight in Tons . E Hauler Name U ©� Q Hauler Telephone.Number ■ Address Same as Hauler Initials -- (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. • • • • - 5 5 4 5 9 2 3 -- A Pick Up �7Delivery 0 U Hauler Tire Program ID / Site Suffix Facility Telephone Number °� DATE .a,� / �®' / �� _ w Whole Tire Count ;�Weight in Lbs., oxo - oaaaao � m 411101-7 lotolcf I ElValume;CubicYas:_YWeight,in.Tons E Hauler Name � h- c� � c Hauler Telephone Number ■ t._1 Address Same as Hauler Initials -- (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE