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Dc$ <br />/jj CA Comprehensive, lip Log and Receipts- Ice B= ` <br />- > "''wo. eC71 �z�, GrsMrsnarto, cat r�sRz - 12E) <br />d E RAM P L E 11 2 Com rehensive Trip�}Numbr <br />:as M4 INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE. STAPLE OR DUPLICATE <br />faQesgre0un/w tiff UQ Mad Rte, V* MV. -IN 017d 1"ro kccr*c®:foa Pra.Admd 4e 1FY Fane eA b.00rufdred ONO drlE9t Tmr�rT end trmde eamae. a+ o wtt, T N CCA, 8aacson <br />VW d w¢, r a rn Y mdrbr - 11 d Ci R CalRecNie wo camtwt es d CIY form r# ** afflow and tde6tu,e resets poWded m eco f1Fm or roeegl. <br />I <br />Truck Decal Humber Hauler Address <br />Business Name <br />Address Q C)s QJA/thl Q 0"'O_ <br />City, State and Zip <br />licenseQ� <br />Plate Number State cc4 <br />Cameron L �j .• <br />1 cowy uric pw 04 0=1m: Cw ��cioZ'aii Cai tt*! ifararCon ellwo b cu and —na tr, eat nw 1 the d nrrtt it arodzmaraleefOl dre:�vs� d RLode <2Ioo bred ra/ t+ U9 Pali w 0 3 2"M pw or wro PM per dq 6 dmc>bed it Rt a f C=— <br />Name (PrE►dj Driverssi atiueV Date <br />5037574 ==e I.-PPick Uo n�.�innr�r�Nij-�'i-idi� <br />Hauler. Tiro Program lD, /. Site suffixDATE <br />Lu'tj %IWO Tis© Count Q Wight in Lbs <br />m <br />� p <br />❑ Vok me Cubic Yds. ❑ Weight In Tons <br />auier Name <br />c c(u r isS � - 6 <br />Hauler Telephone Number • <br />-29 <br />ownComprehensive <br />(WA for <br />Facility'Telephone Number <br />MON-PHN000 <br />Facility Business <br />NamelAddrdss <br />City, S4etwel�- yy�-pU� trci <br />StamAp o a 1w alar <br />oAMWI-, <br />I cB r"Tt1Ar woo Pouu.TY OF Pf Lnw of THE <br />LAY9E OF TIf>!$TAT� ap CAt�R%tA THAT THi"e 1 /~'qi <br />5037574 ®oB 0 ii pick Up Delivery IN D1 N H/ r I � I L I - <br />Hauler rine Program !D � site Suffix DATE <br />c <br />m _ <br />a 001 F aIe Tire Cur <br />ort ElWeight in Lbs <br />as <br />m ❑ vchune Cubic Yds. n Weight in Tons <br />oler'�tame - <br />+; C!Wi.VS <br />auler_Telephone Num • <br />actq.� �N-2-�- whole o"l. <br />7503754 AL�±k e- Up -'-Ll Delivery <br />Hauler Tire Program ID / Slte Sufis .DATE�® <br />) wE] Why Tire Count E]Weight in Lbs. <br />w <br />m 1 7 I ❑ vohnne Cubic Yds. ❑ WeigM In Tons <br />o 7aer Mame <br />a E 1 � <br />Hauler Telephone Number <br />0ir-)ct cin -.>4J. -P7 7 <br />>� Rhes) <br />Facility Telephone Number <br />as � _a-tf <br />Facility Business <br />-Name/Address <br />City, State and rip. ' <br />i ^ )C'' gECYGL1NG <br />Stamp or Label OK•\ <br />Address Same as,Hauler <br />T1 eetra-F TM TATE O fiS LFO of TW.? 1• os TILT - <br />MS OF. � STATE Of �1�Cl�TH/iT�THR <br />�iaiei3'0o1M <br />Facility Telephone Number <br />u�',�3 <br />a d <br />Addres*aTne as Hauler <br />CERTIFY THAT UNDER PiMAM W PERJURY OF THE <br />LAws of THE STATE of CALr-aF GA THAT THA <br />