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ing CA Comprehensive Trip Log and Receipts Dept.of Resources9,Sacr Sacramento,CA 95 812-125y OOOZ P.O.Box 1259,Sacramento,CA 95812-1259 - CBlRf�yC�e EXAMPLE 1 2 3 Comprehensive Tri Number CaMacy;*2 9aiINSTRUCTIONS ON BACK OF PART 2 .DO NOT TAPE,STAPLE OR DUPLICATE By alanine this CA Comprehensive Trip Lop and Reulpt,the slpner(s)request that the Information provided on this form will be considered confidential,proprietary and trade secret.In accordance with Title,14 CCR,Section 17041 at cap.,if a mqusst Is made for disclosure of this Into—ition,CatRecycle will contact the diner(s)of this tam at the address and telephone number provided on this form or receipt- Vehicle Information Hauler Address Truck Decal Number yy�� Business Name �l� a � - seas ® Address X70 1V �� / sC�� J�r City,State and Zip «�r License Plate Number State • oaooaaa oo ❑ Came�n L ... I cenlfy under penally of pert"under the laws of the State or Callfornla that the Information provided above Is true and correct.In addition,I om swam that falsificetlon of lhb nfomtatW�may result In auepenalon,revocatlon,or denial of renewal cf _ the Waste Tire Hauler Registration pursuant to Public Reaourcea Code section 42980 and may result In civil penalties up to S 25,000 per day, etbn«adrrtinlslretive i .ub to:6.000 per vbletb day as de•crl In Rlbfb fieaovices Code section 42W Driver's Name rint f river's Si nature rate Comprehensive Trip Log Number Load Information Facility Tire Program 1 Site Suff ix 4 8 4 612 3 " C Pick Up X Delivery - d Hauler Tire Program ID / Site Suffix Facility Telephone.Number DATE aoo ooaoaoo Whole Tire Count Weight in Lbs. Facility Business y l O © il� ttt� Q r Volume Cubic Yds. Weight in Tons Name/Address o Hauler Name City,State'and Zip U a•, DOE Stamp or Label OK Hauler Telephone Number MNH Address Same as Hauler _ nista/ O - / -0/ff.•/ ( for (CERTIFY THATUNDERPENALTY PERJURYTHE 7 �- Whole 010 Tires) LAWS OF THE STATE OF CALIFORNIACALIFORNINI A THAT THE � I . INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number • • Information • s g 4846123 B- Pick Up Delivery Facility Telephone Number u oa•�• oa � oo Hauler Tire Program ID / Site Suffix DATE -aoa0000 . � a a Whole Tire Count � Weight to Lbs. DOE Facility Business O Volume Cubic Yds. O Weight in Tons Name/Address p Hauler Name City,State and Zip . V � Stamp or Label OK Hauler Telephone Number ■ Address Same as Hauler In tiara (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS OP THE STATE OF CALIFORNIA THAT THE IH FORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 4 8 4 612 3 -- A Pick Up :: Delivery E M701 N H. E n N . n Hauler Tire Program ID / Site Suffix Facility Telephone Number . ' DATE OHM WnW.®.Whole Tire Count E]Weight in Lbs. F �^ Fa' 44r1Al�c,\r C'� (C,► j ^c/ (o if-v,,1 .. t 01011 c7 t- O r ❑Volume Cubic Yds. a Weight In Tons Name/Address J d o Hauler Name City, State and Zip r�U6GY E'A'P��nr•� �j V /--)Oki l/Y ePOENNMEN Stamp or Label OK fpj��p Hauler Telephone Number. [:] Address Same as Hauler initials n L/ rs _ �`/ L/ (NIAole for I CERTIFY THAT UNDER PENALTY OF LAWS OF THE STATE OF CALIFORNIATHAT THE OF THE of ! v �.f Whole Tires) ,! • INFORMATION PROVIDED ABOVE 19 TRUE AND CORRECT. I y��!!!