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<br />CA Comprehensive Trip Log and Receipts . .-10002 .0 BOX 1252, SOCmD—to, CA 95812-12N
<br />..... jEVXjAjMjP1LjEj 111213 Com prehensive Trip Number
<br />1TWYLHOL-
<br />- INSTRUCTIONS ON BACK OF PART 2 00 NOT TAPE, STAPLE OR DUPLICATE
<br />3440259
<br />By WVInq OftC•
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<br />A.e ri ormat on
<br />Truck Decal Number Hauler Address
<br />Business Name
<br />a a o- a Address
<br />sqwo, W�,l, '64 :Vj-q-,
<br />City, State and Zi
<br />L16ense Plate Number State P .5-ro 64�f�, olS
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<br />Driver's Name (Wint) . . - .... - - . . , .: - Driver's Slanature Date
<br />d-34-402-59
<br />Hauler Tire Program.)D 't, Site -Suffix
<br />E
<br />0 Hauler Name
<br />C0 '
<br />I z COO i
<br />Hauler, Telephone Number
<br />De I i vie ry.
<br />Facility Telephone Number
<br />DATE 0�- � / ,a®./,.a® uj E] Whole Tire Count Weight In Lbs. a a `I• ;� �� , a' `
<br />k rpcil4y B'Uin.A (T L•• CIA -1 40 (?try
<br />EgAvoiume Cubic Yds. Weight In Tons Name/Address; -'
<br />e' p 'r :UYIL50A.
<br />City, Stat and jit-NV
<br />43t. ft b ! 6d
<br />p or' a, 1 , �71-06
<br />E 00P .,m S
<br />�c!Ste ame,.. Haul. 4,5
<br />(IN /A f�r FY THAT UNDER PENALTY 01F PEF6M W;HE-
<br />W I STATE OFCAUFORFRAMAT,,t.
<br />Whole Tl.*) uwt OF TME
<br />34,�02-59�-
<br />E
<br />Pick Up_ Delivery
<br />Ll
<br />I A L91 131 N E N — L01 fl
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<br />Hauler I1' �O�Qrlkit:I� /"ili fflx'.
<br />A 1
<br />DATE ®©/ _@0. -
<br />Facility Telephone. Number -
<br />11111 s....
<br />w Whole Tire Count Weight In Lb 7.
<br />Volume Cubic idsl] Welght*I Tons
<br />Sao[o�oflao.
<br />Facility Business 1,71 �'Cks,
<br />;Ndme/Address!
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<br />. . ., .
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<br />tat and.Zi* ':T411
<br />City,: S 0 p
<br />0
<br />Hauler Name
<br />Az- -
<br />'jStampor'Labe10k.
<br />7auler Telephone Number
<br />■
<br />M /A for
<br />Wh.I.TIrss)
<br />Address Samela
<br />ns.Ha? I Id.
<br />UNDER PENALTY IF RE "-'Rv IF TNQ
<br />.'I .LIVII OF ME S11 IF CAUFORPHA THAT IN
<br />WFORNA N PROVIDED ABOVE 6 TRUE AMD CORRECT. /�
<br />Comprehensive Trip Log Number
<br />Load information
<br />Facility Program ID Site Suffix
<br />3440-259-- A
<br />Pick Up Delivery
<br />oTire
<br />0
<br />U,
<br />MG)
<br />Hauler Tire Program ID Site Suffix
<br />DATE
<br />as as oao
<br />Facility Telephone Number
<br />a
<br />a a o o .o
<br />Lbs.
<br />F_- Whole Tire Count Weight in Elr—Facility
<br />Business
<br />Volume Cubic Yd.. []Weight in Tons
<br />Name/Address
<br />oHauler
<br />Name
<br />_000EO00Stamp
<br />City, State and Zip
<br />or Label OmHauler
<br />Telephone Number
<br />-
<br />Address SaKe
<br />as Hauler I Iff.l.
<br />(N/Af.,
<br />Whole Tlm)
<br />I CERTIFYATME
<br />�UAT UNDER PENALTY OF PERjufly Or MTME
<br />LAWS OF E STATE OF CFQANM AT
<br />roR2jM2jL"_ogmD A,m. Is TRUE AND coRREcT.
<br />
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