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Dept.of Resources Recycling and Recovery Oa CA Comprehensive Trip Log and Receipts 10002 P.0.Box 1259,Sacramento,CA95eT2-1259 Ca�REeycle E x A M P L E 1 2 '3 Com rehensive Tri Number ra� oi INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE.STAPLE OR DUPLICATE °` By elpaing this CA Comprehensive Trip Lop and Recalpl,the sipner(ei request that the information pmvlded on thls form will he consld•rad confidential,proprietary and trade secret.In accordance with Title,14 CCR,Section 1704 et seq.,If a request Is made for disclosure of thio information,Celliecycle will contact the sipnef(s)of this form at the address and telephone number provided on this term m receipt. "'Vehicle Information' Truck Decal Number Hauler Address r Business Name I p jDa�U/•') �-t�lo�a C��S'"`I'�Q�v► City,Address ('Dips r License Plate Number .;j r;•; j1 State -State and Zip �, v , �U}( 2� 3u�p �"^-•� ® ® J. R M.Afl '. F ®' E] Carr Bron 5�"DC ' r04 6T52 13 I certify order penalty of perjury under the laws of the State of Cetifornia that the information provided above is true and correct In addition.I em aware that felsuicatlon of this Information may result In suspension,revocation,or dental of renewal of me Waste Tire Hauler Reprstration pursuant to Public Resources Code section 421080 and may result in civil penalties up to S 25,000 per day,pM v tion or ndminisbat."penalties up to$5.000 per violation per day ae described I PudicResourcm Code section 47Z driver's Name tint Driver's Signature Date mprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix . /'+ _ Tr x 4284388 -- C Pick Up; Delivety: a D a-a V. N Hauler Tire Program ID I Site Suffix Facility Telephone Number DATE 00./ 00./ DD . ooa- oaaoaaa � a � Whole Tire Count � Weight m Lbs. Facility Business s_ El Volume Cubic Yds. Weight in Tons NamfYAddress E Hauler Name City,Sta#e and Zip Ua Stamp or Label OK Hauler Telephone Number ■ E] Address Same as Hauler Ininafs (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS.THE STATE OF CALIFORNIA THATTHE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix .r'y. 4 2 8 4 3 8 8 -- 6 Pick Up Delivery Facility Telephone Number Hauler Tire Program 10 / Sit Suffix DATE W SJ 9�m�af l_o•�Scr+�! 0 'l b - 0 a _ D�r � �l3030 . oaa a ©© ooQ ® e �SZf� a ®.Whole Tire Count 0 Weight in Lbs. M }vt �{u,.,,riW Z Facifirr*yll 'ss .a.. Volume Cubic Yds. Weight in Tons Namt1�'ca �•a5 f c Hauler Name City,St,# p t �cl� d.Sf- (2e LkA Stamp r ()r ✓1 �� J Hauler Telephone Number, ■ F-1AddressSame'as Hauler I I O _ 2,q 2 ` 2 7QD (N/A lo far I CERAWS Fr THAT UNDER PENALTY OF PERJURY AT THE OF THE Whole 7,fos) LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT ry Comorehensive Trip Log Number Load Information Facility Tire Program a 4-2-8 4 3 8 8 -- A Pick Up . Delivery a L DATE Facility Telephone Number Hauler Tire Program ID / Site Suffix s� � 'a Q►�o0�'a t�oao��L°�� - . o �r © o a o ro L r � f cjs2 l3 ww ® Whole Tire Count Weight In Lbs. �� FCL f -7 y 7 If I El Volume Cubic Yds. Weight in Tons NtWr�3l62f ss f c Hauler Name Ci Stag enct- yiZen sin }o�gt,ri �yl�,p, r��rs{r►�tt ALT// (/`1 (/'/11 `'�' Lire V Cow-PS Q 1 V V Stam -�,/ ori�►9 9530/ Hauler Telephone Number ■ Address ame as Hauler Initials T /1 (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE ' / I✓ 27�D Whole Tires) LAws OF TNF STATE OF CALIFORNIA THAT THE i' INFORMATION PROVIDED ABOVE 15 TRUE AND CORRECT.