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CsllfomlJi Integnt4iE Wast.Mi negern Board <br /> CA Comprehensive Trip Log and Receipts 10002 r.r.doa 7259,Sacrementq CA M'2-1259 <br /> EIX AIM P (. E1112131Com r,hensiveTri Number <br /> c riemi(iaos INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR DUPLICATE 3 2 7 3 2 5 1 . <br /> By 119,119 mis CAGomprebenelve Trip Lop aIW R...lpl In.MU-06)r.q..A mal U, InbmuUon p-1ded—W.form will be conWdend confld..I.I,Wopd-,y and bad..ecnl.In...Id.—.1.TIU..14 CCR,U. n <br /> 11011 of coq..H—puasl la mads for dlaclasun of mis InfomuUan,01 CIWMB will cpmaa the slgnar)s)of mis loan al N.addnu and Ietephone number on vided on UN.loan or ncelp, <br /> Vehicle Information Hauler Address �/ J <br /> a <br /> Truck Decal Number ��{� i ot('t,1 I-r�L: <br /> Business Name JJl a Address ����r /��CI hC12 f. 14✓6-- <br /> City,State and Zip . k4� <br /> License Plate Number State <br /> a a a a i a <br /> Carrierrn <br /> 1 ceNh ulcer penalty of pa0ury under ma bvn a ma stale of Cahfomia mei tM InlomatwnprvAdod ebova b bu.and oonecl In eatliwn. am—re ThtaNllkaUon a mN hlomubon may""soil M N"' <br /> on.rn• o".a—W a marts of m <br /> W—nre Hauler Reguu—,pursuant a Puck Resources Cow seOl m 42960 arra may raw.c 1 peruUNs up to E 25.WD per day,per v abon or admmua eWe panarW s up to 55.00D par v flmn oar day day w dewlwh Publk Resourdes <br /> CWs w,0—42962 <br /> laeYz�r 07332071520 <br /> Driver's Name pri t) Driver's Signatuie�: Date <br /> NumberComprehensive Trip Log .. <br /> 3273251 -- C Pick UPDeliveryfl H N HIJEE. H <br /> lHauler Tire Program ID I Site Suffix Facility,Telephone._Number <br /> DATE oo ©� <br /> Whole Tire Count Weight in Lbs. <br /> a (Facility Business I e).514dd Tth G <br /> 2-Iq o lfq 1C,III - vl()I I Volume Cubic Yds.0 Weight in Tons Name/Address 137 5'j. C0ty se9ce 5 <br /> Hauler Name City,State and Zip.340c kAu„ &t-tq ire) <br /> v qnC{� RUCIiQ'�OC` a �a � �a Stamp or ss Same <br /> a <br /> r � Address Same as Hauler <br /> Hauler Telephone Number ■ rnnrars _ <br /> �T�I C (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> p{VST) �I Whole Tlrpe) lAM9 OF TNN STATE OF CALIFORNM THAT <br /> THE ! <br /> INFORMATION PROVIDEDAsOvE Is TRU AND CORRECT. •'-' <br /> Comprehensive Trip .. Number Load informationProgram <br /> 3273251 -- B / Pick Up Delivery <br /> Hauler Tire ID 1 Pro ram .SiteSuffix Facility Telephone Number <br /> g � .,;� � I: DATE `I^` <br /> ID <br /> a E—]Whole Tire Count Weight In Lbs. <br /> Fac y�i�es�Q�l/ <br /> i 2 clO cicl1 ,61A D Volume Cubic Yds.E]Weight in Tons' N et ess / y <br /> E Hauler Name Cit �(id <br /> .n an� �,ao� a ROD"a2-nn staHauler Telephone Number Q Address Sarne as Hauler Initials <br /> I CERTIFY THAT UNDER PENALTY.OF PEAJUM OF THE <br /> OF THE$TATE DF CA FOANIA THAT THE' <br /> INFORLUTION PFtOVIOEO A90VE 19 TRUE/WD CDRRECT. . <br /> Comprehensive trip Log Number Load . Program <br /> 3273251 - -.A Pick Up . ,� Delivery _ <br /> MEERE H E <br /> 11 Hauler Tire Program ID / SiteSuffix Facility Telephone Number <br /> DATE <br /> E- do-Hfflw <br /> PER E <br /> 1M9 w []Whole Tire Count OWeight In Lbs. <br /> f [F$F(iAMki®aIft <br /> F!E®V6LfN8 <br /> 112ACIMIC11 l I loll (]Volume Cubic Yds.®Weight in Tons NaFONUIFORNIA INC. <br /> oHauler Name' cfbf5 ALTAM <br /> ONT PASS RD. <br /> 4t�c1 S RCK��Ct�oC a 00�� �� sLI,VERMO.RE;CA 94550-9745:, <br /> ■ <br /> Hauler Telephone Number Q0Q)d9334jMs Hauler rnlDa 4: <br /> �-�T (N to for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> �''-`T N 63- 95 Whole Tlree( LAWS OF THE STATE OF CALIFORNIA THAT THE 4 <br /> MFORMAnON PROVIDED ABOVE le TRUE AND CDRitECT. <br />