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'� Dept.of Ro•ourcoe Recycling and Rocovery CA Comprehensive Trip Log and Receipts 10002 P.O.Box 1259,Sacramento,CA 95812-1259 Comprehensive Tri Number Ca1ReCyd0 nn x A P E 2 y r�ri INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE By signing this CA C—prep—s"THp Lou end R.c.lpt,th..ipn.r(.i n:I—t lh.l ato informetbn provided or this form will b4 considered confid.ntiol,propritlary and trod...cr.l.In accordant.w1U,Till.,14 CCR,Section 17011 t e.q.,U.rsgwat Is mad.for disclo.un of this 1.1—tk n,C611-yd.will contact th..Iprwrl.)of this form at th..dd—.r,d talepho—numb.,provided—this form or receipt. y-efi 1610-1 Information. Truck Decal Number Hauler Address � q�� Business Name Address CD License Plate Number State City, State and Zip fax a13�3o L Q J t ❑ Common L D ,❑ ❑ D D . ©.D Carrier cM�fy undw penally of Per)tey-05 N.1-11 of the SIe!a o!Ca fo,na that ISM information Provided Roo-1.!rue and—t.In admtion,I ant aware!nal!a MI—tion of Ih!s Inform.!*'rl.y result In suspension,rervoCellnn,w denial of renewal of. the Wase T4.Hsulw R stlation susn!to bhc n Code section 4nW and may MS.11 in clvll FW ItJm Up fo$75,000 par day, a a.dmi Vst' Up o TRF day ss Abed In bsc Resources i" 2ZI Driver's Name tint river's Si nature Date Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix Pick Up.. Delivery a Hauler Tire Program ID / Site Suffix Facility Telephone Number ATE Doi 00: 00 - • � DDD- 0000000 -. UJ E Whole.Tire Count E] Welght in Lbs, g Facility Business ❑ Volume Cublc.Yds, Weight in Tons Name/Address o Hauler Name City, State and Zip V � Stamp or Label OK Hauler Telephone Number ■ ❑ Address Same as Hauler r (N/A for - I CERTIFY THAT UNDER PENALTY OF PERJUR_y OF THE '1 - Whole Tirea) LAWB OF THE STATE OF CALIFORNIA THAT THE ter— INFORMATION PROVIDED ABOVE til TRUE AND CORRECT; Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Stiff ixn 5733015 -- B Pick Up Delivery /,� ® D �--® y I 'Facility III Telephone`Ntamber m Hauler Tire Program ID / Site Suffix _ r f N �•rl�u�rt �?�f/UItG./ DATE ro '7�_gv� `��3a.® Whole The Count Weight in Lbs. r e � � Q Volume Cubic Yds. Weight in Tons - L-YA�ddrads a uler. a tC�1`t9' al zj,/ ,r.C(G!D � f U G'ff°" ✓' V 417oi i ee J, , so��►P • �r ' A{dros's�Same as Hauler J Haurererelephan �lymber , - - - (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF T11C CO - - Wholo Tires)• LAWS OF THE STATE OF CALIFORNIA THAT THE vv i iPP7 INFORMATION PROVIDED ABOVE 18 TRUE AND GORRECL Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 5733015 -- Aj :, �( . 11 oD Pick Up : Delivery ,' 6 E D 5 D a- r f-"' Facility Telephone Number Hauler Tire Pro ram ID / Site S}r(fix DATE a �A Jo�gl)t h /Ir1A� �Or1SPIr�1D�'1 �U { w Ir Whole The Count Weight In Lbs. J�vLI� 3 9s�3 ® g rj Si `a f 7l` Volume Cubic Yds, Woight In Tons Iflhl'��7.Zddf uier o Qlarn Ey7�a en (r� J n3 - U �r V 7h w. L-•o ��. � �art�s•ci�LabeYGK Hauler Telephone Number ■ ;Q Address Same as Hauler ,/ar —f ^,/� ^/�^ tN/A for I CERTIFYTHAT UNDER PENALTY,OF PERJURY OF THE V / 7' �,•7(� Whole Tlras) LAWS OF THE STATE OF CAUFORNIA THAT THE a pr eeeaaa///"' INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT.