COMPREHENSIVE TRIP LOG and RECEIPTS ORDER FORM, Calrecycle 681 (Rev 05/10)

STATE OF CALIFORNIA Department of Resources Recycling and Recovery (CalRecycle)

CalRecycle 681 (Rev 05/10)

COMPREHENSIVE TRIP LOG AND RECEIPTS ORDER FORM

Orders should be sent 30 days in advance to ensure delivery by the needed date. There is no charge for the Comprehensive Trip Log (CalRecycle 203) form. Please order your estimated use for 3 MONTHS.

As part of our service to waste tire haulers the California Department of Resources Recycling and Recovery (CalRecycle) also provides online ordering at www.calrecycle.ca.gov/Tires/Forms/Manifest/WTMSOrder.asp for the CTL form.

Requested forms will be mailed within 3 business days of receipt of your completed request. Please note that you must have a Tire Program ID (TPID) number in order to request forms.

Tire Program ID: / Order Date:
Requestor’s Name:
Phone Number (include area code):
E-mail Address:
Company Name:
Business Mailing Address:
City: / State: / Zip:

Please enter the requested amounts from the following formats:

Haulers Only

Choose one of the following: / Comprehensive Trip Log Forms (CalRecycle 203)

Quantity

Individual Forms:
(maximum 50 forms)
Packages:
(100 forms per package)
(maximum 12)
Boxes:
(800 forms per box)
(maximum 10)

______

Signature of Authorized Agent Date

Return Completed Order Form To:

California Department of Resources Recycling and Recovery (CalRecycle)

Tire Hauler Compliance Section

P.O. Box 4025, MS-10

Sacramento, CA 95812-4025

FAX (916) 319-7605