Laserfiche WebLink
Resour <br /> Recycl <br /> g and Recovery <br /> IZ CA Comprehensive rip Log and Receipts l�Pt ax 1269,SC•• mento CA95812-125 <br /> 100x2 . P.O.Flax,259,Sacramento,ca asa,x-,xsa <br /> CafROCyCle I E I X I A 111 1112131Comprehensive Tri Number, <br /> INSTRUCTIONS ON BACK OF PART 2 .DO NOT TAPE,STAPLE OR DUPLICATE : 4846209 <br /> t.• - SY eigning this CA Comproh—shre THP Lop and Recolpi,the slpnar(s)request that the Information provided on this form will be considered confidential,proprietary and trade secret.In accordance with THec <br /> Ie,14 CCR,9don <br /> 17041 at ase.,N e request u made for disclosure of this Information.Coll1acycle will contact the slgn,r(s)of this form at the address and telephone number provided on thls form or receipt. <br /> Vehicle Information 251.=MM Hauler Addres <br /> Truck Decal Number <br /> N <br /> BusinessNamesM - ® © D a © Address <br /> City,State and Zip <br /> License Platee Number State G, L q <br /> O V O a © omm <br /> on I J O(A I A. �A <br /> Ca Her : 1�2 I <br /> I canity under wary of parlury under the lam of the State of Cdlfornia that the Inlpmation provided amus Is true and Correct.In addltlon.I em aware that falsification of this Inlormatlon may result In suspension,revocation,or denial or renewal of <br /> the Waste The Hauler Registration purauerd to Pubilc Resources Code section 42960 and may result In civil penalties up to S 25,001)per day,per violation ora�dminlatrative paneales up to$5,000 per vlolatlon per day as described In Public flesourcos <br /> Code section 4 902 . 71,S i• 14 <br /> . <br /> jr_ <br /> Driver's Name TintSignature <br /> Driver's '4 � uJ� 1t. LUDate <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> r <br /> 4846209 -- qtl"x <br /> Pick Up Delivery a HEM � -a: <br /> f1 <br /> Hauler Tire Program ID / S / Facility Telephone Number <br /> DATE. M0 / ,a©'/ 0© _ <br /> W ®Whole Tire Count []Wolght In Lbs. <br /> nz no ® o©ooa � o . <br /> Facility Business <br /> Volume Cubic Yds. E]Weight In Tons Name/Address <br /> o Hauler Name } City,State and Zip <br /> U r '� 1 Stamp or Label OK <br /> a. 111 <br /> Hauler Telephone Number ■ , Address Same as Hauler <br /> I!/ Q �] IN/A for ICERTI Y THAT UNDER PENALTY OF PERJURY OF THE (� <br /> 'g} i�� ` -1- O S Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> INFOIitNA710H PRO'VIDEO ABOVE IS TRUE AND CORRECT {{{ <br /> • • • Log Number •. • Information Facility Tire Program '.i <br /> n 4 8 4 6 2 0 9 -- B Pick Up Delivery <br /> Facility Telephone Number Hauler Lire Program ID / Site Suffix ..DATE•M2 / ( / � • <br /> • <br /> � a ® Whole Tire Count E] Weightin Lbs. . . <br /> F� frty aresto <br /> O O as loll Volume Cubic Yds. E] Weight in Tons i A itsc Hauler Namean ` � <br /> V & ( 9tall�ppQJr'Cabel�Er' 9,5� 0 <br /> Hauler Telephone Number ■ Address Same as Hauler <br /> 6�59 ( for I CERTIFY THAT UNDER PENALTY PERJURY OF THE <br /> b Whole 01a Tires) LAWS OF THE STATE OF CALIFORNINI A THAT THE <br /> tNFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire ProgramY�` <br /> ,i <br /> 5 4846-209 A Pick Up Delivery 1 1) 222 R K ' R, F�. <br /> 'a) Hauler Tire Program ID / Slte Suffix � :• Facility Telephone Number DATE � r'�• �® Mfl <br /> w ®Whole Tire Count Weight.in Lbs. <br /> li ♦ <br /> [F(.1 R' Busies ys <br /> E]-Volume Cubic Yds. [:]Weight In Tonsr�E �lc <br /> pHauler Namej'tt' in�? e`(OQQ ��• <br /> U TJN r, ~ S410 6r�a�L�AC `, .a5 2..�r3 <br /> �d <br /> ■ l Address Same as Hauler l Rr <br /> Hauler Telephone.Number ti <br /> .a (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OFT HE <br /> O <br /> (/�' _ Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> L2_() [J 4 01-5 INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT..- <br />