Form CalRecycle203 "Ca Comprehensive Trip Log and Receipts - Sample" - California

What Is Form CalRecycle203?

This is a legal form that was released by the California Department of Resources Recycling and Recovery - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2010;
  • The latest edition provided by the California Department of Resources Recycling and Recovery;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CalRecycle203 by clicking the link below or browse more documents and templates provided by the California Department of Resources Recycling and Recovery.

ADVERTISEMENT
ADVERTISEMENT

Download Form CalRecycle203 "Ca Comprehensive Trip Log and Receipts - Sample" - California

744 times
Rate (4.6 / 5) 45 votes
Toll Free 1-866-896-0600 / www.calrecycle.ca.gov/Tires
Dept. of Resources Recycling and Recovery
CA Comprehensive Trip Log and Receipts
10002
P.O. Box 1259, Sacramento, CA 95812 – 1259
Comprehensive Trip Number
State of California
INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE
CalRecycle 203 (7/10)
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 trade secret. In accordance with Title, 14 CCR, Section
17041 et seq., If a request is made for 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.
Vehicle Information
Hauler Address
Truck Decal Number
Business Name
Address
City, State and Zip
License Plate Number
State
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 information may result in suspension, revocation, or denial of renewal of the
Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to $ 25,000 per day, per violation or administrative penalties up to $5,000 per violation per day as described in Public Resources
Code section 42962
Driver’s Signature
Date
Driver’s Name (print)
Load Information
Comprehensive Trip Log Number
Facility Tire Program ID
Site Suffix
Pick Up
Delivery
Facility Telephone Number
Hauler Tire Program ID / Site Suffix
DATE
Weight in Lbs.
Whole Tire Count
Facility Business
Name/Address
Volume Cubic Yds.
Weight in Tons
City, State and Zip
Hauler Name
Stamp or Label OK
Address Same as Hauler
Hauler Telephone Number
Initials
I
CERTIFY THAT UNDER PENALTY OF PERJURY OF THE
(N /A for
S
C
LAWS OF THE
TATE OF
ALIFORNIA THAT THE
Whole Tires)
.
INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT
Load Information
Comprehensive Trip Log Number
Facility Tire Program ID
Site Suffix
Pick Up
Delivery
Facility Telephone Number
Hauler Tire Program ID / Site Suffix
DATE
Weight in Lbs.
Whole Tire Count
Facility Business
Volume Cubic Yds.
Weight in Tons
Name/Address
City, State and Zip
Hauler Name
Stamp or Label OK
Address Same as Hauler
Hauler Telephone Number
Initials
I
CERTIFY THAT UNDER PENALTY OF PERJURY OF THE
(N /A for
S
C
LAWS OF THE
TATE OF
ALIFORNIA THAT THE
Whole Tires)
.
INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT
Load Information
Comprehensive Trip Log Number
Facility Tire Program ID
Site Suffix
Pick Up
Delivery
Facility Telephone Number
Hauler Tire Program ID / Site Suffix
DATE
Weight in Lbs.
Whole Tire Count
Facility Business
Name/Address
Volume Cubic Yds.
Weight in Tons
City, State and Zip
Hauler Name
Stamp or Label OK
Address Same as Hauler
Hauler Telephone Number
Initials
I
CERTIFY THAT UNDER PENALTY OF PERJURY OF THE
(N /A for
S
C
LAWS OF THE
TATE OF
ALIFORNIA THAT THE
Whole Tires)
.
INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT
Toll Free 1-866-896-0600 / www.calrecycle.ca.gov/Tires
Dept. of Resources Recycling and Recovery
CA Comprehensive Trip Log and Receipts
10002
P.O. Box 1259, Sacramento, CA 95812 – 1259
Comprehensive Trip Number
State of California
INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE
CalRecycle 203 (7/10)
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 trade secret. In accordance with Title, 14 CCR, Section
17041 et seq., If a request is made for 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.
Vehicle Information
Hauler Address
Truck Decal Number
Business Name
Address
City, State and Zip
License Plate Number
State
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 information may result in suspension, revocation, or denial of renewal of the
Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may result in civil penalties up to $ 25,000 per day, per violation or administrative penalties up to $5,000 per violation per day as described in Public Resources
Code section 42962
Driver’s Signature
Date
Driver’s Name (print)
Load Information
Comprehensive Trip Log Number
Facility Tire Program ID
Site Suffix
Pick Up
Delivery
Facility Telephone Number
Hauler Tire Program ID / Site Suffix
DATE
Weight in Lbs.
Whole Tire Count
Facility Business
Name/Address
Volume Cubic Yds.
Weight in Tons
City, State and Zip
Hauler Name
Stamp or Label OK
Address Same as Hauler
Hauler Telephone Number
Initials
I
CERTIFY THAT UNDER PENALTY OF PERJURY OF THE
(N /A for
S
C
LAWS OF THE
TATE OF
ALIFORNIA THAT THE
Whole Tires)
.
INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT
Load Information
Comprehensive Trip Log Number
Facility Tire Program ID
Site Suffix
Pick Up
Delivery
Facility Telephone Number
Hauler Tire Program ID / Site Suffix
DATE
Weight in Lbs.
Whole Tire Count
Facility Business
Volume Cubic Yds.
Weight in Tons
Name/Address
City, State and Zip
Hauler Name
Stamp or Label OK
Address Same as Hauler
Hauler Telephone Number
Initials
I
CERTIFY THAT UNDER PENALTY OF PERJURY OF THE
(N /A for
S
C
LAWS OF THE
TATE OF
ALIFORNIA THAT THE
Whole Tires)
.
INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT
Load Information
Comprehensive Trip Log Number
Facility Tire Program ID
Site Suffix
Pick Up
Delivery
Facility Telephone Number
Hauler Tire Program ID / Site Suffix
DATE
Weight in Lbs.
Whole Tire Count
Facility Business
Name/Address
Volume Cubic Yds.
Weight in Tons
City, State and Zip
Hauler Name
Stamp or Label OK
Address Same as Hauler
Hauler Telephone Number
Initials
I
CERTIFY THAT UNDER PENALTY OF PERJURY OF THE
(N /A for
S
C
LAWS OF THE
TATE OF
ALIFORNIA THAT THE
Whole Tires)
.
INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT
By initialing this Comprehensive Trip Log (CTL) receipt, the signer(s) requests that
information provided on this form will be considered confidential, proprietary and / or a
trade secret. In accordance with Title 14, CCR, Section 17041 et. Seq., if a request is
made for disclosure of this information, CalRecycle will contact the signer(s) of this
form at the address and telephone number on this receipt.
By initialing this Comprehensive Trip Log (CTL) receipt, the signer(s) requests that
information provided on this form will be considered confidential, proprietary and / or a
trade secret. In accordance with Title 14, CCR, Section 17041 et. Seq., if a request is
made for disclosure of this information, CalRecycle will contact the signer(s) of this
form at the address and telephone number on this receipt.
By initialing this Comprehensive Trip Log (CTL) receipt, the signer(s) requests that
information provided on this form will be considered confidential, proprietary and / or a
trade secret. In accordance with Title 14, CCR, Section 17041 et. Seq., if a request is
made for disclosure of this information, CalRecycle will contact the signer(s) of this
form at the address and telephone number on this receipt.
Page of 2