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Dept or Ring and r <br /> CA Comprehensiv( 'p Log and Receipts 1 80.13=1290.SMCi =t0,CA01812-1259- <br /> CwEXAMPLE 1 2 3 t Com re#iensive Trip Number <br /> '°•"wmx*wP,/YQ1NSTRUCT1ONS ON 13ACK OF PART 2 DO NOTTAPE.STAPLE O I-DUPLICATE 5)037 57 <br /> Oy sk.#rp tds CA +TF4�G srd ra�t,t,t+.ap�.pt rwyrp can to mroatsan 11ad m db Sana sN e•= red oofdf trrr1%o CPMN,and vds.K�re.In•omllw�ace Ttts.14 ate.D«tIm <br /> 1011 d a°O.■.rsgasss Y Oak kw aWur.•of OftM^wrcaOpq Canae)d..d1 eorLcl L1.obwtq d tri.tan•t the 1- s.rid t6eatcem amber provided m tits Cora or aotpt <br /> Abide <br /> Truck Decal Number n <br /> Hauler Address <br /> v� 5 <br /> Business Name <br /> ®IL'J —� H O N 0 <br /> W <br /> - Add Gil Q <br /> C/d? W • \f C�SQ����� <br /> license Plate Number State 4 State and Zip <br /> •�1UlrC)1.i C �Ct ��� �' <br /> Old 0 0 9 9 0 0 © 11 Carrier ommon <br /> 1 ow wy ud•r pa-ay d ps cam'Mw 7m*bo or W s"a d &.9 L1•Flamtn7n pr;rAdod&b*-b Cu.and=aa In to mqpergY37,rwwo r%or donW of rerm l of. <br /> t+s 1Y;G Tko <br /> 7q, <br /> p�rstani r Rffica9r n ad*yY aatII�dN MMOM up to 3 25=per sty. or w o Cc p�dr/1.0=14.]h R bw Rouxva <br /> 11{p"\li i % 1 \+1 <br /> Driver's Name ®river's _ Da/te <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 5037575 Pick Up. .! ®slivery <br /> m Hauler-Tire."ram ID / Site SuffixDATE / / Facility Telephone Number <br /> Ed <br /> old o0 <br /> Lu p Who e� ,t 0 Weight in Lbs. 44 <br /> Va!ume Cubic Yds. Weight in Tons <br /> E Hauler Nam ZipY<n <br /> S° , e � � <br /> r�ibi <br /> 00 jfs-Lulil <br /> Hauler Telleyp�yhone�Number E00HEWHO D Address Same as Hauler —j <br /> R W rde I QSiS0:7 TNAT'M'M O PMAI-"fY�LtIAiY�r Tl� <br /> 15hOlp Tv'•O) lAlYb�TT@ STATE OF cwr�►THAT Tifc <br /> C1PDi MATgM PVDVMNM ABOVE for TINE AND COASFCS <br /> Comprehensive Trip Log ... information Facility Tire Program ID Site Suffix <br /> CL 5 0 3 7 5 7 5 -® B Pick Up Delivery i <br /> D �7 <br /> m Hauler The Program ID / Site Suffix Facility Telephone Number <br /> DATE `� �00©-RHa0H14H <br /> a ❑Wholo Tire Court a Weight in lbs. <br /> r Facility Business <br /> I 17 �j I I E]Vch=e Cubic Yds. ❑WeEght In Tons Name/Address <br /> oZer Name- City,SSM Mpumfi® <br /> v ~ 1 Stam a 97��trc�tkYi� <br /> Hauler Telephone Numbert � ■ 1:1 Addams as Ha l <br /> `?. 1 i� ..moi L I �[ �� -• holoOVA 1'07. 1 CBZAM OF THAT VM O CALIF I/OF THLAT i- THE <br /> /!1•�'" f �� Ji (� Wap j� LAM o•THE srATE of C1tL¢01twA zt1AT Tic <br /> - <br /> MM M P'AOWDFD ABOVE O TM AMD GgdtECG <br /> Comprehensive Trip Loci • •n Facility Tire Program ID Site Suffix <br /> VL 5037575 -- APick Up r] Delivery a — 0 ONE <br /> Hauler Tire Program ID / Site Suffix DATE / j Facility Telephone Number <br /> Whole Tire CnturL ❑ Weight in lbs. K,�,yt <br /> F- eVolumo Cubic Yds Weight in TarTs a ��\, "Q <br /> cEaur Name `6 to d ZI}t� <br /> vv 1 �-s <br /> Hauler Telephone Number ■ ❑ Address Same as Hauler <br /> WA fw I CSMFY THAT I XnM PEMAM Corr PER.AM OF TIL: <br /> ®� Wbc%Tcw) "Mf OF THE STATE OF CX.W-MD THAT THE <br /> 0ffOiL9ATWM PROVIDED ADa<13 MZ AMD=©MCS <br />