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CA Comprehensive Trip Log and Receipts Dept.of Resources Recycling and Recovery <br /> X0002 R0.Box 1259,$ecramento,CA95812-1259 <br /> CajReC Cje EXAMPLE 1 2 3 -- Comprehensive Tri Number <br /> YF4.421255 <br /> Scral�ydM°° �movirmINSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE <br /> By signing this CA Comprahaneive Trip Log and R•caipt,the elgnerlal requost that the Informallon provided on this form will be considered confideneol,proprietary and trade secret.In accordance with Tllle.14 CCR,Section <br /> 1704/at seq.,If a request Ia made for dleclosure of thla Information.CelRecyoie will contact the ignerls)of this form at the address and telephone number provided on this form or receipt. <br /> �•� <br /> yehicle.Information _ ;f:'> <br /> Truck Decal Number HaulersNamAddress I Pit L/es <br /> Business Name Pit <br /> (l <br /> C ® © ® © � ® Address Zg1O F . f z r u 1-� S*- <br /> City,State and Zip ' <br /> License Plate Number State CA- <br /> Baa ® ® aa a ® oCommon <br /> �f� �ta � <br /> Carrier <br /> I entity under oanahy of perjury under the laws of the Slate of California that the information provided above Is true and correct.In eddltlon,I am aware that latetlicaijon of this Irflormation may result In suspension,revocation,or dental sof renewal of <br /> the Wasta Tire Hauler Registration pursuant to Public Reawrcea Code section 42960 and may result in cM penalties up to$25.000 per day,per vloiati IsJrathme las up to SS,ODD per violation per day as deaenbed in Public Resources <br /> Code section 42962 �(/I///�r•/�v/1 <br /> bk4 <br /> Driver's Name fgrinp ..Driver's Si nature /Date�— <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 4421255 -- C Pick Up Delivery <br /> Hauler Tire Program ID 1'.Site Suffix Facility Telephone Number <br /> DATE <br /> w ®Whole-Tire�Count L Weight in Lbs. <br /> o� Ll <br /> x }' t .. I RiU-mess <br /> �, 0 _ ElVolume Cubic Yds. � Weight in Tons• �'.P[elAddress <br /> E Hauler Name1. £ �Erste <br /> rJtiltIf S ity G SVt a41�f��t�� ol� <br /> rrk auleLL�TTrrr•,---.leg11LL'OQp1fn11Q NumbPeA ■ Address Same as Hauler Initials <br /> t '"ToC \ 5-- r7 'YO (N/A for (CERTIFY THAT UNDER PENALTY OFPERJURYE THE FTI <br /> G ! f! r l/N11 Wh010 71x09) �ri8 OF THE$TATE OF CALIFORNIA THAT THE <br /> _ INFORMATON PROVIDED ADOYE IS TRUB AND CORRECT. <br /> ayeaer <br /> • • • Log Number • • InformationProgram I/ Site Suff ix ' <br /> 4A21255- -- B © Pick up Delivery a161 PRE MLl <br /> ©- 0 <br /> Hauler Tire Program ID / Site Suffixcc DATE a� / © � Facility Telephone Number <br /> way®Whole Tire Count We'ght In Lbs. <br /> r� <br /> �tY pIs�'�- <br /> Volume Cubic Yds. Weight in Tons ame/Add gess <br /> EHauler Name <br /> U !!/' •//cam �!✓� YUP � Stalf��ilor�+ak�lY�ch' , <br /> a <br /> tiauler T I ' hone Nuritber Ed-■ Address Same as Hauler , •- fril Iola <br /> QQQ lA for _1 CER71FY THAT UNDER PENALTY OF PERJURY OFTHE (. <br /> .Z,f,CJ �j+r G oC>.�� Whole Tires) LAYy9 OF THE$TATE OF CALIFORNIA THAT THE / <br /> ��/ /// INFORMATION PROYIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suff ix <br /> :- 4 4 212 5 5 -- A Pick Up I JDelivery j �/ 1A, Id- <br /> Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix DATE <br /> c - w ®Whole Tire Count a Weight In Lbs, <br /> HEM No �-Moos ® <br /> I L I' rtility V11.S.3 s it <br /> 1 J / � ar. Volume Cubic Yds. Weight in Tons IK T�/A,tlrts;�`1 <br /> o Hauler Name i Ylspiel <br /> 4 ODOP <br /> 7�rtld x7P�. V <br /> 2, NHM <br /> ■ Q. Address same as Hauler <br /> ,Hauler Telephone Number rnrn I ' <br /> ^1 /e N -� (N/A for •I�CERTIFYTHATUNDER PENALTY OF PER JURY OFTHE <br /> G/ ` ��O Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> [„�'✓ J INFORMATION PROVIDED ABOVE 19 TRUE AND CORRECT. <br />