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Dept.of Resources Recycling and Recovery CA Comprehensive Trip Log and Receipts 10002 P.O.Bos 1259,Sacramento,CA 95812-1259 Ca1Recyc1e EXAMPLE 1 2 3 Comprehensive Tri Number t ;,q INSTRUCTIONS ON-BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE �'9 5 'r By signing this CA Comprehenalve Trtp Log and Receipt,the slgner(a)request that the Inlormetlon provided on this form will be considered confidential,proprietary and trade secret.In accordance with T1Ua,14 CCR,Section 17041 at seq..If a request Is made for dlsclosum of this Inf—U ,CaMiicycla will contact the slpner(s)01 this form al the eddresa and telephone number provided on this form or recalpt. Vehicle Information Hauler Address — Truck Decal Number Business Name � u'\�`�� r� Address License Plate Number State City, State and Zip E Common 000000E EE Carrier I cenity under panolty of perjury undo,rhe Dawe c1:I•a Stale c1 Caitornio that the infonratlon provided above is true end correct.In oddit'.cn;I am aware that falalficbtlon of thla Inlormetlon may rea.h In au lulon,revxatlon,or denial cl ra.newnl of. Ma Wes:e Tire Hauler Hegivatwn pursuttat to Public R-mes Code eecllor 42980 and may result in cm penalties up to S 25,000 per day,per violation or administrative pshaNas up to 5.5,000 per viola on pd day'. fwd In Public Rosources Code Zion 42982 1 Driver's Name Tint ,• Driver's Si nettire - Date Comprehensive Trip .. Number Load Information Facility Tire Program 48574-49 -- C Pick Up Delivery 0 Hauler Tire Program ID / .Site Suffix Facility Telephone Number . � .. DATED® / aa / aa o LUCz Whole® Whole Tiro Count � Weight in Lbs. oEa oaoa000 Facility Business a �I I Volume Cubic Yds. Weight In Tons Name/Address o Hauler Name City,State and Zip V) r?)T u O 1 `L Stamp or Label OK Hauler Telephone Number ■ Address Same as Hauler n,rre,a. {N/A nor I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE rj OOJ Whole Tiresi LAWS OF THE STATE OF CALIFORNIA TNAT THE 4 \ �p ` INFORMATtON PROVIDED ABOVE IS TRUEAND CORRECT. \\ Comprehensive Trip Log Number Load Information Facility Tire am ID Site Suffix 4857449 B Pick Up Delivery E E E E E E E-E E U E Facility Telephone Number d Hauler Tire Program ID ( Site Suffix D EE � DATE aw E Whole Tire Count Weight In Lbs. Facility Business EVolume Cubic Yds. Weight in Tons Name/Address o Hauler-Name City,State and Zip* UStamp or Label OK Hauler Telephone Number. ■ Address Same as Hauler ,nrrrar9 __J (N/A for I CERTIFY THAT UNDER PENALIY OF PERJURY OF THE• - Whole Tires) LAW6 OF THE STATE OF CALIFORNIA THAT THE . INFORMATION PROVIDED ABOVE 19 TRUE AND CORRECT. Comprehensive Trip Log Number Load • • Program -- 4 8 5 7-4 4 9 .-- A Pick Up1:1 Delivery a © EEE. []NFacility Telephone Number ar Hauler Tire Program ID / Site Suffix DATE Eo ®- N M qaao Cal ® Whole Tire Count Weight in Lbs. Facility Business 1 q ,q Volume Cubic Yds. Weight In Tons Name/Address E Hauler Name City, State and Zip 1J r C(n 0 Y Stamp or Label OK v a 44 1 • Hauler Telephone Number R■ N E Address Same as Hauler' rR r (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE ZO r 15 Whole Tires) LAWS OFTHEN STATE OF CALIFORNIA THAT THE lJ l INFORMATIOPROVIDED ABOVE 13 TRUE AND CORRECT.