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Dept of Resources Recycling and Recovery <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 <br /> 1e <br /> �alRec CE X A M P L E 1 2 3 Comprehensive Tri Number _ . <br /> r2>p y�INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE ° <br /> By signing this CA Comprehensive Trip Log and Receipt,the signer(,)request that the information provided on this form will be considered confidential,proprietary and trade secrot In accordance with True,14 CCR,Section <br /> 17041 of seq.,H e request is made for dlsetesuro of this information.CatRecycle will contact the signerls)of this form at the address and telephone number provided on this form or receipt . <br /> vehicle Information Hauler Address <br /> Truck Decal Number <br /> 1/1 <br /> PBusinessa a a. D ® Name OMEGA .TIRES <br /> Address <br /> City, State and zip 1321 Rockefeller Dr. F2 , <br /> License Plate Number State - Ceres,:CA 95307 I <br /> o © a © ago as EiCarieron <br /> I cenify under penalty of perjury under the laws of the State of California that the information provided above is We and correct.In addition,I am aware that falsification of this information may result in suspension,revocation,or.denial of renewal of <br /> the Waste Two Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to S 25,000 per day,per violation W administrative penalties up to S5,o0D per violation per.day as described in Public Resources <br /> Code section 42962 <br /> Driver's Name(print). Driver's Signarure Date <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> . <br /> Q :4:3 <br /> 66-662 <br /> - L� Pick Up Delivery 3. 3 <br /> o a oaaooaa o . <br /> Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix DATE <br /> a •Whole Tire Count- [] Weight m Lbs. <br /> H ny <br /> vFas <br /> s <br /> V-1 �,S / I 101-? Volume Cubic Yds. 0 Weight in Tons . l eso <br /> me/Adcility�BuG+rs�s <br /> o Hauler Name City,Staten ZI <br /> O A N Cx- I)'"` a . . V O Stam rar10K) t3,� C. . <br /> U Hauler T e honQNumber F d ss Same as Hauler rnllfars <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> VV INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suff ix <br /> 4 4 6 .6 2: - B 'Pick Up Delivery b a a <br /> I <br /> Hauler Tir Program ID Site Suffix p <br /> ho <br /> facilityTelephone Number.. <br /> � / <br /> cc DATE <br /> 0 <br /> (� ©'�.:� <br /> .__ wa Whole Tire Count Weight m Lbs. <br /> oaa 000000 <br /> g r ! ., . <br /> (� Volume Cubic Yds. El <br /> Weight in Tons L, d s <br /> o -Haul6r Name,•-'' ' C hi Sl�le an �( <br /> J. <br /> CDUERR ' <br /> =..Stamp';or Label=CSK <br /> U: a <br /> Hauler Telephone Numb r ■ D ❑ .Address Same as Hauler 'rnrlfars: <br /> (N/A for I CERTIFY TRAT UNDER PENALTY OF PERJURY OF THE <br /> IID y, 7® � � _ Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT.THE .' •{ .,� .,r�� <br /> !"' VVV PPP INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suff ix <br /> .21 N A <br /> 4366662 -- A IJ <br /> Pick Up �-Delivery <br /> . Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix DATE .D a / NR <br /> / EA <br /> a Eq Whole Tire Count E]Weight In Lbs. <br /> Facility' Business lAhouc 5 ,C, 04 <br /> U U 7 Volume Cubic.Yds. Weight in Tons Name/Address. <br /> 0 <br /> Hauler Name 'City,State and Zip .IQ <br /> U S O V Stamp or Label OFC <br /> a V <br /> Hauler (episome Number ■ [:] Address Same as Hauler_ rn;r;als b <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> 5- �(/j/ _ I Whole Tires) INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br />