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Dept.of Resources Recycling and Recovery O CA Comprehensive Trip Log and Receipts X0002 D.Box,25B,Sacramento,CA958,2-,2ss >~ Cal Recycle' Com rehensive Tri Number EXAMP L E 1 2 3 i4 j Wf� 0)INSTRUCTIONS ON BACK OF PART.2 DO NOT TAPE,STAPLE OR DUPLICATE `° ` By signing this CA Comprehensive Trip Log and Receipt,the signer(s)request that the Information provided on this form will be considered confidential,proprietary and Veda sacral.In accordance with Title,14 CCR,Section 17041 of seq.,If a request is made4or disclosure of this information,CalRecycle will contact the signer(s)of this form at the address and telephone number provided on this form or receipt. VehiclL"Ififormation . Truck Decal Number Hauler Address i Business Name �f)� �S �T►�e Address r � l-tz�y City,State and Zip `- License Plate Number State :i Qj C ❑ Common ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Carrier I certify under penalty of perjury under the laws of the State of California that the Information provided above Is true and correct.In addition,I am aware that falsification of this informatlpn may result in suspension,revocation,or.denial of renewal of 1. the Waste i Tire Hauler Registration pursuant to Public Resources Code section 42M and may result in civil penalties up to S 25,000 per day,Per violation or administrative penalties up to$5,000 per violation per day as described in Public Resources '-' Cotle seclirardf982- -. Dr' error s Name-( rinQ- Dnvees Signature • Date - Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix 4438012 -- C Pick Up Delivery ❑ ❑ ❑ ❑ ❑ ❑ ❑-❑ ❑" I aI FacilityTelephone Number I Hauler Tire Program ID / Site Suffixp 1 DATE D❑ / FIE / E L . o ® aaaa ❑ a❑o N w a LE.Whole Tire Count 11 Weight in Lbs. /❑ '{'t}/�/ J/ 44,/Vi' II L ClEl aI G /f Volume Cubic Yds. Weight in Tons ,,,a5m�-/tidd es 10 cHauler Name tamAdEire s Ces Hauler . Hauler-Telep�ro eLNL36er ❑ Initials .J Jam_ (WA for 1 CEHf1FY THAT UNDERPENALTY OF PERJURY OF THE "X �O/r-GO C•�/ Whole Tares) LAMS OF THE STATE&CALIFORNIA THAT THE f t "FORMATION PROVIDED ABOVE IS TRUE AND CORRECT. 77 Q 4438012. -- B Pick Up Ll Delivery a ❑ ❑ ❑-❑ Hauler Tire Program ID / Site Suffix Facility Telephone Number DATE �� / ❑© / �� P N aa ❑ ®aoeaoo aw a Whole Tire Count n Weigbt in Lbs. c ' �, ) .7 I;b I ❑ g ' � � � Volume Cubic Yds. Weight in Tons " 'may/A dr / '• E ,Hauler Name mit Sta a Zip �� /� HaulerrTelephone Number ■ ❑ :Address Same as Hauler Initials f�/ `• �� / - ( for .1 CERTIFY THATUNDERPENALTY OF PERJURY OF THE Wholeole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE. INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suff ix, EL 4.438012 -- A OPicklUlp ❑ Delivery o 0 0 0 o a a o a Facility Telephone Number Hauler Tire Program ID / Site Suffix DATE ❑ / ©1� / m h / w Whole Tire Count Weigh in Lbs. A g Fac ity Business v ( I 101�7 C/ I/ ❑ Volume Cubic Yds. Weight in Tons Na e/Addrdg5 -7- Haulr�-z 0er Name 2I Stateland ip 1' ��// U M'N EA/ Hauler•Telephone Numbe I E ■ Address/M' Same ,as Hauler ` (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE Whole Tires) LAWS OF THE STATE OF CALIFORNIA THAT THE t-7 t D INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. t.