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Toll Free 1-866-896-0600 / www.caIrecycle.ca.qov/Tires/ <br /> Dept.of Resources Recycling and Recovery <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA95812-1259 <br /> comprehensive Tri Number <br /> CalRecycle E E 1 2 3 5545906 <br /> stale m canyons, <br /> calRac,Ge2lzRnnB)INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE <br /> By signing this CA Comprehensive Trip Log and Receipt,this signor(s)request that The information provided on(his form will be considered confidential,proprietary and trade secret In accordance with Title,14 CCR,Section <br /> 17041 et s q If n request is made to disclosure of this Information,C(Recycle Will contact The signer(s)of this form at the address and telephone number provided on this form or receipt. <br /> tll a eh'cle lnform`8tron Hauler Address <br /> Truck Decal Number Business Name <br /> Address 2.32-3 �L )o JP_�C� <br /> ❑ �r <br /> 171 /� r Cita, State and Zip <br /> License Plate Number State m " C4f 933 <br /> ❑ ❑ Common j (i ► l�Z /� ❑ <br /> ❑❑ a Q kJ <br /> Carrier L— <br /> I cenihy under pe,talty of perjury under the laws of The State u1 Califc,r, that the inlPrma6on provided above is true and correct.In addition,I am aware thatorlad(min tior,of This inl es up to fmation may$5.0re ult in suspension, <br /> per ev described Inocaticirr.or 'Publle Resourcesal of remewal <br /> Code <br /> �hc Wo.te T'lre Heiler Peyisl tion purs�.,ant to Public Resources Coyle sec:run 429CO and may result in cwd penalties up to b 25.000 per day,per vl <br /> Code section 42962 �iyei's <br /> Driver's Name(print) L� ture Date <br /> . . • . . r, <br /> M Mal <br /> 70r <br /> _o Pick Up Delivery ❑ ❑—❑ ❑ <br /> 5906 C ❑ Facility Telephone Number <br /> re Program ID / SiteSuffixDAT ❑❑ ❑❑F] Whole Tire Count ❑ Weight In Lbs. <br /> y0., <br /> ~ ❑ Volume Cubic Yds:.❑ Weight in Tons <br /> oHauler Name <br /> OEOOE" <br /> U Q ❑ Address Same as Hauler <br /> Initials <br /> i"attler Telephone Number (Nie for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> _.. Pick Up Delivery 0 �— <br /> Q 554590 ❑ ❑ 0 ❑ � 0 <br /> � Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix <br /> U <br /> W <br /> Cr r DATE <br /> og <br /> / ❑� / <br /> io � �-oaoaoa � <br /> to <br /> Lu F] WholeTire Count ❑ Weight n Lbs. <br /> { ❑ Volume Cubic Yds. Weight in Tons' <br /> m + <br /> pl4auler Nante <br /> U L0Vf-1,�dC,-_—Vfa A&,&i <br /> y <br /> Q � 1 P0 ACidre SS Sanl(: qS Ha t11ei" initials <br /> HaulC,I' .Bleph One NuIT117P"r ICERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> (N/A for <br /> © �.S Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THIOE <br /> 7 rjVJ <br /> INFORMATION PROVIDED ABOVE 15 TRUE AND CORRECT. <br /> r.t_ Pick Up Delivery — p <br /> �- 5545906 A �C 000 ❑ ❑ ❑ ❑ <br /> Q ❑ ❑ <br /> Zia <br /> Facility Telephone Number <br /> v Hauler Program Tire Pm ID / siteSuffix <br /> l <br /> � DATE �.�❑:�0 /.. `❑, � � <br /> c ww ❑ Whole Tire Count ❑ Weight.In Lbs. <br /> 000 no❑ 000c <br /> I T <br /> l7 ❑Volume Cubic Yd � <br /> s, n weight in Tons <br /> D� IDI C <br /> oHadley Name <br /> rn Q 1 <br /> 7 ev <br /> U Q ❑� Address Same as Hauler initials <br /> Hauler Telephone NumheY I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br />