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--.Ii1■e..r� — Dept.of Resources Recycling and Recovery CA Comprehensive Trip Log and Receipts 10002 P.D.aaat259,Sacramento,CA95812_1 E X a IMIP L E 1 2 3 Comprehensive Tri Number . CallecyCle t r,tr+�.q"lIne INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE 4852751 By signing this CA Compnhenatve Trip Log and Receipt,the signer(a)request that the Imormadon provided on this form will be considered confidential,pmpriatary end trade sacnst.In accordance with Title,t4 CCR,Section +7041 at seq.,N a request is made for diselosure of this kdomration.CalRecyc4 v.111 contact the elements)of this form at the address and teisphone rumlwr prcvlded on this form or receipt. Vehicle Information Truck Decal Number Hauler Address Business Name �YUnnDn ��frE Address L� City, State and Zip License Plate Number State I •+ ; ❑ Carieron �— J I certify,undr penalty of perjury under the laws of the State of California that the information provided above be true and anrect.In addition,I sm aware that falsification of intonmatlon may result in euspenalon,ravocal on,a denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code mctlon 42960 and may result In c10 penolles up to$25,000 per day,per ddation or administrative pefi0iir up to 35,000 per vMitllon par day es described in Public Resources Code section 42802 -- river's Name rant river's Si nature Date.- Comprehensive ' . . Number LoadProgram 4852751 -- C Pick.Up. Delivery Hauler Tire Program ID / Site Suffix Facility Tble9phone Numb—e1r• c DATE ©N / D® / �® _ >` ui Whole The Count Wei ht in Lb © a to CL�� ❑ 9 s + Facility B'ksiness ❑Volume Cubic Yds. ❑ Weight in Tons Name/Address c Hauler Name City,StBtand Zip . JAY(AV"\to D ( Y� E00DEWHE Stamp or bel OK Hauler Telephone Number ErAddre s Same as Hauler initial (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE .'•�'i••O J` Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE \ INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. • • • •e •- • .• • • Program x 4 8 5 2 7 51 -- B Pick Up Delivery .� DDD Hauler Tire Site Suffix ID Program / l Facility Telephone Number � g DATE CID / DD / DaV . • _ D DDDDDDD ❑ Whole'Tire Count ❑ Weight In Lbsl. .116 Facility Bslness d I I . ❑Volume Cubic Yds. ❑Weight In Tons Name/Ad ass - - E Hauler Name City,Statnd Zip Q U E * Stamp or[ bel OK ■ Adcf(E Same as Hauter Hauler Telephone Number )�FYTHATUND RPENALTYOFPERJURYOPTHE •i: nRl re - � (N/A for < Whole Tires) LAYfS OF THESTA OF CALIFORNIA THAT THE.. '• - :INFORMATION PRDED ABOVE 19 TRUE ANO CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 4852751 -- A Pick Up DeliveryRP-27Hauler Tire Program ID / SiteSuffixFacility Telephone Number� DATE ; . c w ,• 'Whole Tire Cont la® a.-o®a o ® © H a , u ❑ Weight in Lbs. 0 { 1 .- ' �•❑Volume Cubic Yds. ❑Weight in Tons Vit h�Y�lf1�c£�hL—OO i A E Hauler Name hYi�tatg�`` 'g i2 t L�? 9 Stamp or Label OK < LJ ■ Address Same as Hauler. J Hauler Te ephone Number 1� ❑ ?initials ra c. '' Fy+... if:t y (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE 47 L ��a'�r,�'O\ Whoia Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE �� .. F INFORMATION PROVIDED ABOVE M TRUE AND CORRECT.