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-CA Comprehensive ip Log and Receipts it, 2 PO.Bof ox1 � °9W; 2 <br />'M E X A All P L E Y2 3 Comprehensive. Tri.Number <br />a1,`+r= n'gINSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE. STAPLE OR DUPLICATE 7 5 <br />CD/ 9$P& efts CA COnpr h—f- TMp t.Oo and Rftv4; • the e�+�«t*a -*+a6t Ci+A 0* 6ltonnrJorl "kUd Or, Wa loan VXN be 0MW duad mnSldnntld• . <br />17061 et eep.. It s Mqueet V M"o for dfeclo u a edo Irdametlon, Cd Rat M aril Cnh tie WC—tat d eda f— et the P tW on trade wast, 4+ pt�nw adtl, TTOo, f0 CCR Oedlar+ <br />ehlcl l tl �O °"Q �^ �°" °^ rhta toren «,arAtyl <br />Truck Decal Number Hauler Address6 U 0�'� n / <br />Address Business <br />Name CI tie <br />Plate Number State <br />City, State and Zip <br />Ucense Pl�J Y <br />®a a ®®®.©o ❑ Carrieron I <br />1 nrufy unOat para oor)ury under the U a the SYIIsi a the 4do.rncoan ceo a b tn,. ena co S 25 T.(IkAk-i <br />2,jo(I"'M9-2Q_ ,a den:d W rv+ev�vl a <br />uD b i 27,Ylol6tlurl Or . Jnl6tr055000 per r dry ay d.1bd L, 11,w Reooucaated. <br />Driver's Name(print) Driver's Si Date <br />y <br />5.0.3 7 5 718- -- C 'Pick Up : ' Delivery <br />Hauler Tire Program ID / Site Suffix" <br />f _ DATE ®®/ ®f CL! C <br />/ U.1 Whole Tire count ❑ Weight in Lbs. <br />m / 5 7 ® ❑ Volume Cubic Yds. ❑ Weight In Tons <br />oauier Name ` L vV..J�� �� <br />S <br />Hauler Telephone Number E/ERMUE <br />JWA Tor <br />Whala <br />/ 1 ols Tlresl <br />a 5037573 -- B <br />a Hauler Tire Program ID / Site Suffix <br />cc <br />c <br />a <br />g <br />a o <br />Hauler Narile• <br />UFIFT 1,71 F <br />L V-1 LIPJ LB Vj <br />Facility Telephone Number <br />f®®_0 <br />�I�la MXTP <br />��,`V� <br />Cvlolz"q <br />ZipYW � AAI / .S <br />❑ Address Same as Hauler J <br />I CeFMFY TWAT UNOM PENALTY OF PERJLMY OF THE <br />LAWS OF THE STATE OF CAUFOFMA THAT THE <br />Pick Up Delivery J "�{_P] j , I ®M <br />DATE <br />• / ©® /. Facility Telephone Number <br />�u) 1� / <br />❑ Whole Tire Weight ht In Lbs. M—amill � 2 lr 1 <br />❑ g <br />V <br />❑ Volume Cubic Yds. ❑Weight in Tons _ esp 9 I Qin Q <br />Hauler Telephone Number <br />uvn IPI CnCI IDIVU IIIIJ LUY IVTInIC <br />'5037578 <br />1 <br />a Hauler Tire Program ID. / Site Suffix <br />QD S1 2-21 <br />I_- <br />0 Hauller Name <br />H/au(lle'+\r` Telephone NN/jumm/ber'/�//��^ <br />'.G S <br />.y <br />■ Address Same as Hauler <br />(NIA for 1 CEMIFY THAT UNOM PENALTY OF PORJURT OF THE <br />Whop `nme) L.AWf5 of THE STATE Or CAUFOR" THAT THe . <br />Pidk Up - .Li B E r] Delivery .14 13113.11 d C <br />i <br />DATE Facility Telephone Number <br />u1. Whoio Tire Count Weight In Lbs. <br />o 11g a <br />Facility Business <br />Volume Cubic Yds. ❑ Weight In Tons Name/Address <br />City, State and <br />Com, Stam or I <br />J p I abet OK L <br />C.� ■ E] Address Same as Hauler t <br />(WA for I CERTIFY THAT UNDER PENALTY OF PER.IURY OF THE / <br />Who4e T1M*) LAM OF THE STATE OF CALAFORNIA THAT THC � ^� <br />INFORMATION PROVIDED ABOVE M TRUE ANO tY1R2FCT / 1 <br />J <br />L <br />