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Calmarttla Inbpnbd Warta Managart»rtt eoatd <br /> CA Comprehensive Trip Log and Receipts 10002 P.o.Box UKSacramento,CA95812-12" <br /> WHEENi <br /> ---_-- -- -- -r---- _ Comprehensive TripNumber <br /> yINSTRUCTIONS,ON-BACK.OF PART 2' DO NOT TAPE STAPLE OR DUPLICATE 3957270 <br /> -try signing tha CA Cornpratw atv Trip Lag and RPM47L the slgner1q)request am fire Information provided an Orta form WO be considered eorCtl•nn.l.Proprietary ars!4'.d•••erui.to scowdaxa wft Title,14 GM Section <br /> 11041 at eeq.,A a mq,nst to made for dlaclosure of this Information,the C11111111121 wM contact the•lgo wts)of this form at the eddrw•am bi•pborw owb•r prwldsd on this form ar Ieea1PL `�= <br /> Truck Decal Number Hauler Address <br /> Business Name <br /> Wi;ngfoot Commercial ir <br /> Address. <br /> e <br /> City, State and Zip 1000 S.21st Street <br /> License Plate Number. State Fort Smlttl AR 72901 <br /> 0 00 a 9QU 1J,.H carmr#eron <br /> ' L_ J <br /> I certity under penalty of perjury under the Iowa of lne state at Cahfarnla trial fine Informawn provlded above Is true and coned.In addition,I em swaro drat hti'Mat+^^of this Information may rosurt In"pension,r—cotion,or denial of renpwil of th - <br /> West.Tire Hauler Registration pursuant to Public Resources Code section 42960 anti may result In civil penalties up to S 25,000 per day.per violation rn adndnlatrative perrarres up to 55,000 per violation per day as described In Public Resources <br /> Code socticn 42962 <br /> U nv i14 Dfi►ers t,a re Dace <br /> Drivers Name rint g <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 3957270 �+ ,Pick Up Delivery 7F] 0-0, <br /> as <br /> I Hauler Tire'Program'ID / Site Suffix Facility Telephone Number. ' <br /> DATE,❑❑ � 0[] <br /> � ❑❑ <br /> D <br /> w Whole The Count W®foist In Lisa. ty <br /> Faciti Business <br /> `m Volume Cubic Yda.❑Weight in Tons Name/A re s <br /> Hauler Name C#ty,Stat Z3 <br /> Ca <br /> Stamp or ,abet OK <br /> Hauler Telephone Number ■ F] Address Same as Hauler <br /> (N!A for I CERTIRr TYtT TINDER PENALTY 01+PEAduRY OF TNM <br /> YY1101a 711'") U1riS O!'TN9 STATS OF CAUM$NA THAT TIQ <br /> Comprehensive e •a • asInformation •a <br /> 'c <br /> �• Pick U Dellve <br /> 3957270 B _ pry a a o ® �- saaafloi <br /> Hauler Tire Program ID I Site Suffix Facility Telephone umber. <br /> .1a. DATE ®E <br /> C r , w�®'Whole The Count ❑Weight In Lisa:' <br /> 9 Facifity Wlh Mt Commercial The <br /> `. S E] Volume.Cublc Yds.❑Wolght In-Tone NarnelA �4 &P: Wilcox rub ; <br /> E Hauler Name . . City,st9ti + '►�'t CA.95215 <br /> 0DEOR'n <br /> f -. <br /> v EStamp or Label OK <br /> Hauler Telephone Number . Address Same as Hauler <br /> (NIA f� I GERMY THAT UMM PENALTY CIS P AM of TM <br /> YYhoh Tlr") LAWS Or TM WATe of CALvonil T1tA T.mO <br /> • • • Log Number Load InformationProgram <br /> ,g 3 9 5 7 2 7 0 A .Pick.Up Delivery' <br /> : . . <br /> Haule_r The Program ID / Site Suffix Facility Telephone Number . <br /> DATE © � 0©; UE _ <br /> ®Whole,Tire Count,-❑Weight In Lbs: <br /> ORRRHH � HH <br /> m 1 �. hi D volume`Cubic Yda.[]Weight in-Tons IN mei ddr�"3s y ,� <br /> E Hauler Na is <br /> t S� ��C1 <br /> Address Sam Hauler,Telephone Number �[ <br /> (N lA fol l THAT Wil PEMALTY <br /> _ {�/ �•.}. 1�.� <br /> Who ��!_ LAMfi OF TM0 STATH Or CALIFCRIM 711AT TIS. yy.,,r - <br />