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-CA Comprehensive ip Log and Receipts ' 1� z P08°of xR� °9W;2 <br /> 'M E X A All P L E Y2 3 Comprehensive. Triv:J <br /> Number <br /> a""'Z0 n'gINSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE.STAPLE OR DUPLICATE .757. <br /> D/s3Cnhg1 nw cA Ccx+prelanslss hop t-oo and R+ ot.th0 mv+e N�+•6L Ci+A ca 6ntvnlutlo+t pTOcleed On Us form vrd be rx abaed onfldnntld• . <br /> 17)61 ot M%,It s nque•t V wade for dl.ekawe Of tfla Irdart+.tlon,CWR"Id Wei enrY ow 64—jeS.1ltd.f—.1 the P tW on Ws <br /> wast.4+p with T1Co.10 CCR 0ect— <br /> ehlci Information <br /> ff o^p ruxnber prOYFQ.d on rhh form«r.�yt <br /> Truck Decal Number Hauler Address6 U 0�'� n / <br /> Business Name <br /> Address t (/Q S L1� <br /> Co"L" 1 Q CI tie <br /> Ucense Plate Number State City, State and Zip Y <br /> V 7, <br /> ® a a �.® ® ® .© o Q CComm <br /> arrieron I <br /> I mnoy VWN pwwqy of perjury und@ th. nbw to true end carpo.M oOWIOn. ears diet JmCru[ <br /> d..Ytavb H R mry rpet4t h sttJDMaIOn,r.rpC3110fy a d.n:d W rvgvrvl 01 <br /> e°mrctbn p:ruall I!O Re6o� Code 625ia0 erid mry R M c:Yd pOr-�Iw up b ti 27,DfH1 sbkdbrl or .Jnl6tre!; 055.000 per Y40LCSOn pe day eT deacnbed L�Pubkc R.00:scae <br /> G C3 { 2� <br /> Driver's Namerant Driver's Si Date <br /> ID <br /> Comprehemsive Trip Loq Number Load Information Facility <br /> 5.0.3 7 5 718- is Pick Up Delivery <br /> o � � a <br /> Ix Hauler Tire Program ID / Site Suffix / f Facility Telephone Number <br /> tf . _ - - DATE <br /> ® ®- oar ® © <br /> � �•®Whole Tire Count � Weight in Lbs. <br /> / ' t� v <br /> L3 Volume Cubic Yds. Weight In Tons -m �d rd �,`� <br /> oAauler Name CMteWZip�WS <br /> • <br /> Hauler Telephone Numbe/yr� E/ ER.EE Address Same as Hauler „ <br /> f WA far - 1 CeFMF f T"T Ui'MM PENALTY OF PERJLMY OF THE <br /> / 1 Whol•Tlr" LAWS OF THE STATE OF CAUFOFMA THAT THE <br /> Comprehensive Trip� NFORtM71(NI PROygEp AROVE p TRUlf AND <br /> { • ^ • <br /> grani ID Site SLJffiX <br /> AL 5037573 -- B Pickup 'Delivery '> EEd <br /> w HaulerProgram ID / Slte Suffix • EE / �©® /• Facility Telephone Number <br /> cc DATE <br /> C3 <br /> � ❑ Whole Tire Count Weight in Lbs. <br /> u: L �v <br /> p. o Volume Cubic Yds. Weight in Tons es <br /> 0CHauler-Name'Hauler-Nae- <br /> S an ., f S ewe <br /> z am o a e i.(3K.—k �� <br /> Hauler TefapFione Number ■ Address Same as Hauler <br /> (NIA;., 1 CERTFY THAT UN=PENALTY OF PERYJRY OF TWE y <br /> Who%`nme) a.L.AW5 OF THE:STATE O.CAL WOM"THAT THE . <br /> otvoRt-1 7 PRwIDEDA80VEaTRLEANDCOIGiLCT <br /> {° Comprehensive Log Nurnber LoadInformation • <br /> Site Suf fixr <br /> 5037578 ®- APick Up Delivery I {I t 7 D® C <br /> Hauler Tire Program ID./ Site SuffixDATE Facility Telephone Number <br /> � <br /> Whole Tire Count <br /> Wel ht In Lbe. <br /> a <br /> f ❑ Facility Business <br /> / <br /> ® ®A Voluma Cubic Yds. E]Weight In Tons Name/Address <br /> ler Name (�— City,State and <br /> 4v`S �1� Stam -'' <br /> p or Label OK � - <br /> Hauler Telephone^Number ■ E] Address Same as Hauler t , <br /> (N/A for 10ERTIFY HE SUNDERTATE <br /> PENALTYOFPEWJURYp THE <br /> via <br /> Wh Wp T7r�) LAWS OF THE STATE OF CAL¢ORNLA THAT THC <br /> __ INFORMATION PROVIDED ABOVE M TRUE ANO CORRECT. <br />