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Dept of Ring ma r <br />CA Comprehensiv+< 'p Log and Receipts 1 Ro. 13= 1299. SMCi=cX1t0,CA05ET2.1259- <br />CME X I A M P I L I E 1112 3 t Com re#iensive Trip Number <br />k a°a'vnaINSTAUCTIONS ON BACK OF PART 2 DO NOTTAPE. STAPLE OR•DUPLICATE 0 03757 <br />Oy skr#rp uds GA +TF4 �G srd ramex c,M W caa t7e mrostsan puM- - web Sana Vol* =MjdwW oatdttWfmk --=, -d trod. ssa.L. In . > u=, Tgte. s.14 aBctIm <br />ttott do <br />d. ■ s rsp Y Oak MQ aWu-" of Oft hSarcaWq CM019CICJG still eortacY <br />LWOW W d thb tan et 7s sd�- rd ttl atcem r=tw praAdsd m Oxy los, or McakA. <br />Truk Decal Number n Hauler Address �C 5 <br />Business Name <br />®tL'J O ENO <br />® Address�a <br />License Plate Number - State 4 State and Zip <br />Carrier " <br />f arWy ud•r party d psrjcry arlrl tlfe 1t+o d W tSTza' d Vrt Lti hlamt�jn P'�'ded.bow b true ob cortnct. h adSai 1 s.+ Cttt dam rq¢T iv@ h sum, ar dond d tmrs7�l d . <br />t1R 1Y; G Tko 7c,.7 <br />cY9r at id * yY rmtII �dN MISOM UP to 3 25= per qty. or� CQ p�asct.:n 11{p-\ -Vi <br />Driver's Name jjpfirTQ Driver's Signatuna Date <br />Hauler Telephone Number <br />q 923 -Comprehensive Trip Log Number <br />7— <br />S 5037575 -® B <br />m <br />ID Hamer Tire Program ID / Site Suffoc <br />o auler Name' <br />3Hauler Telephone Number <br />VL 5037575 -- A <br />Hauler Tire Program ID / Site Suffix <br />C <br />1. c;1511-2 3 21 0 / <br />aZler Name <br />co 9V� � i-c,�rs���, 1 <br />Hauler Telephone Number <br />f l Pick Up.. lP Delivery <br />o.�oo��o�oo <br />Lu ❑ Whole Tire Count 0 Weight in lbs. <br />Volume Cubic Ydx Weight in Tons <br />(MA for <br />Whw& Toon) <br />Pick Up I I Delivery <br />DATE <br />0.a Whole Tire Court a Welg in lbs. <br />E] Vah=e Cubic Yds. ❑ Weight in Tons <br />OVA tor. <br />Whwa Tb -SA <br />Facility Telephone Number <br />F <br />Zip a5�1V1.� <br />� Y <br />r�ibi <br />DAddress Same as Hauler <br />I AM CW THAT LAX O CALF YU TW W T►rr <br />lAlYb � � STATE OF cam► THAT THE � l`•j� <br />Facility Telephone Number <br />0H© -®®I© 0oc <br />Facility Business <br />Name/Address <br />City, S eKMPUM4S0 <br />9�7 t�rk <br />5taDr.m�'��i � <br />Ej Address Same as Hauler <br />1 CE WMY nW UXM5t PEMAM OF PERARY OF THE <br />LAM Ma a TIM SIAM OF CAUFOMA THAT T!C ■ ( .4 <br />DATE Facility <br />�jTel ephone Numb <br />m Whole T l_J <br />ae court ❑ Weight m lbs �CQ <br />qFii :evolumoCubic Yds. welgM in TansTer ras <br />Address Same as Hauler <br />WA for I CMnFY THAT MM PETIAITY OF PE RAW OF TIL: <br />Who% Tep) LAM of THE STATE OF CALA--M A THAT THE <br />Comprehensive . <br />Log Number <br />CL <br />5037575 <br />-- C <br />m <br />U <br />m <br />Hauler-Tire.Program ID <br />/ Site Suffix <br />d. <br />m <br />c <br />m <br />o <br />`H/auler Name <br />!� 00 t--11- S i� <br />ml�4 <br />Hauler Telephone Number <br />q 923 -Comprehensive Trip Log Number <br />7— <br />S 5037575 -® B <br />m <br />ID Hamer Tire Program ID / Site Suffoc <br />o auler Name' <br />3Hauler Telephone Number <br />VL 5037575 -- A <br />Hauler Tire Program ID / Site Suffix <br />C <br />1. c;1511-2 3 21 0 / <br />aZler Name <br />co 9V� � i-c,�rs���, 1 <br />Hauler Telephone Number <br />f l Pick Up.. lP Delivery <br />o.�oo��o�oo <br />Lu ❑ Whole Tire Count 0 Weight in lbs. <br />Volume Cubic Ydx Weight in Tons <br />(MA for <br />Whw& Toon) <br />Pick Up I I Delivery <br />DATE <br />0.a Whole Tire Court a Welg in lbs. <br />E] Vah=e Cubic Yds. ❑ Weight in Tons <br />OVA tor. <br />Whwa Tb -SA <br />Facility Telephone Number <br />F <br />Zip a5�1V1.� <br />� Y <br />r�ibi <br />DAddress Same as Hauler <br />I AM CW THAT LAX O CALF YU TW W T►rr <br />lAlYb � � STATE OF cam► THAT THE � l`•j� <br />Facility Telephone Number <br />0H© -®®I© 0oc <br />Facility Business <br />Name/Address <br />City, S eKMPUM4S0 <br />9�7 t�rk <br />5taDr.m�'��i � <br />Ej Address Same as Hauler <br />1 CE WMY nW UXM5t PEMAM OF PERARY OF THE <br />LAM Ma a TIM SIAM OF CAUFOMA THAT T!C ■ ( .4 <br />DATE Facility <br />�jTel ephone Numb <br />m Whole T l_J <br />ae court ❑ Weight m lbs �CQ <br />qFii :evolumoCubic Yds. welgM in TansTer ras <br />Address Same as Hauler <br />WA for I CMnFY THAT MM PETIAITY OF PE RAW OF TIL: <br />Who% Tep) LAM of THE STATE OF CALA--M A THAT THE <br />