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GINamis Inb 'MtW Wast- M.Mgp nt Bab <br />CA Comprehensive Tri Log and Receipts 10002 P.0.Box 1759,5•Dr.OMnta,CAs58,7-1759 <br />Com rehensive Trip Number <br />EXahIP L E[ 111213 <br />cnv"re"m�f"° ",99.VINSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE. STAPLE OR DUPLICATE - 3440260- <br />By •lynlnp INI• CA CanpnMn•Iw Tdp Lag •M R•wlpl, On •Ipwna) I•gwsl U1•I tlN blormFlbn p,oNEM m N4 brm MII M wnNhr•d ooMlbn41, proprMbry •nd 4.6 P•er•l b we•----- vIN TM•, i• CCR. B•cllon <br />11011 N ••Q, M • n0w•1l• m•d• ler dl•down al tlda IrdarmatloR IMCIVMB MII eenbet 11M dpn.r(•1 oI N41pm •I IA• addnsa •rM b4plwn• nan0•r provk•d an NI• loan or r•e•IpL ; <br />a c ormat on <br />TrucEk Decal Number <br />Hauler Address <br />Business Name f <br />Q <br />Address <br />31� <br />License Plate Number State <br />City, State and Zip <br />'` "• t.'-'r� l'v.,�Y y <br />❑Carrie on('%�'J <br />I eanYr ana•r pan•ny a.pMw ander um b • ot,Yw Sob of GIIMrYa Ihal Dn InbrmWw provlC•d .now b au• •nd oortPcl.ln •ddNw; •m •av M•1 hIFMu Nb Inlonntlfon m•y —01 b •u 11- nw. or d•nm a nwral a rN. <br />Wah TF• M•uhr plFtrapon punuanl b tlic Rewu dlon 1796 •nd may nwY In cMl p•rWYw w b f 2"0" M dry, p•r Mal•1 dminbtraY •rWYn W b f6,000 par day r d e.d In Puedc Ra•oumr <br />Codd •Mbr,178 ' t <br />9�}cra�i,r <br />220070483 <br />Driver's Na a j'rant Driver's Signature Date •� <br />a 3440260 =- C E Pick up EDelivery <br />Hauler Tire Program ID Jo. Site Suffix Facility Telephone Number <br />DATEME ./ /' / ,'� <br />.� <br />W <br />w. WholeTlre'Count Weight in Lbs. i <br />(� �j I' o n'` rFacllity Business; yEs i--Q� t7 ,rQ <br />t. V{ qr It ❑ Volume'Cubic Yds.❑ Weight in Tons Name/Address <br />E <br />b <br />:O <br />Hauler Name City, State and Zip: S +. <br />v� <br />-!' <br />. %/-.�.ryU4ti` >.,�_ 'Startup or Label OK ; olkTD�:�il <br />Hauler Telephone Number..: a •❑❑❑ a ❑Address Same:as Hauler.` /mB,l„ <br />• L <br />1//� (N /A IDI I cwmI —Y UNDER PENALTY OF.PERJURY OF THE <br />.... WhoM Tiro) �;' <br />'Q . •-, r L' ✓. I t-�L�a:. � .. " ' � ��', . � r ..,. f INFON D TON �AVIDED ABOVE MV TNUI ANO CO RE .. �' • <br />• • • •••• • • • •• 1 Site Suffix <br />a3'4..4-0'2GO <br />--,.B . ,. Ick'u.p1 =❑ D•eliy�ery �i a �f a o—L�J'IJ <br />d. <br />1 <br />ir <br />Hauler Tire Program ID =/ Site Suffix Facility Telephone Number <br />DATEa� /. _-gPRERE o <br />- w •hole Tire Count' ❑ Welghtln Lbs: <br />y. <br />n � Facility Businessi e,l <br />I (y _ si tl :: {�, '❑ Volume dubic Yda. a Weight in Toni Name/Adtlress -trl il - <br />E <br />y <br />U) <br />U <br />City, State and Zip <br />'Hauler"Name' <br />p `(tet 9 q t. 1''I A I sS ST <br />L P�Yljl',J y ,l � � 6 sl�mp or Label OK i <br />000�0a00 <br />11-1 uler Teleplione_Number a ❑ Address Same as Ha6ler <br />(N /A for I CMnFY THAT UNDER PENALTY OF PERJURY OF TNE' 1 <br />J. TIrM) LAWS OF TME STATE OF CAl1FORMlA TN11T TN! . <br />INFORIMTON PROVIDED ABOVE IB TRU! AND CORRECT. <br />Comprehensive•Log • 9 Site Suffix <br />34402610. -� A 7Pick Up ❑ Delivery 0 0 0 0 0 01A 0 <br />� <br />Hauler Tire Program ID /: Site Suffix DATE Facility Telephone Number <br />.. ... Facility <br />wa ❑Whole Tire Count 0 Weight In Lbs. <br />Facility Business <br />`y <br />�. ❑ Volume Cubic Yds. []Weight In Tons NameJAddress <br />E <br />t) <br />City, State and Zip <br />Hauler Name, ... , <br />_ <br />❑❑❑❑❑ ❑❑ Stamp or Label OK <br />a <br />Hauler Telephone•Number ❑Address Same as Hauler r,lrn•/, <br />I CERTIFY THAT UMDER PEM "OF PER "OF 1N[ <br />- Wllole ural t.A8n1 OF TME STATE OF CALIFORNA TM11T na <br />piFO-MN PROVIDED ABOVE IB TR E ANO DDRRECr. <br />