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Cwatomta Ir%Wztpd Wast.Yanayan» rd <br /> nt Boa <br /> CA Comprehensive Trip Log and Receipts 10002 P.o.B"I=. ft,CASM2-TZM <br /> ?{(,�tA ld 1 P �,��� Comprehensive Trip Number <br /> ow emr�raogINSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE1, . 39571 <br /> ft tlrt CA Cam r•hnn M TdP Lep:mrd Rac•tPR ar•slglrl t*)t•qu•u atrt 0u bdorm•am proNd•d m all•Wm alit be cor lOn'•d Mandi 1,pnopH•tary and trada.aaaL m Simloilil WO TI0•,T•CCR,S•aDon <br /> 17041 t•oq.7 a nqu•ld Y mod•for dbcb•ta•df 0fa 6m'mosCon,al•Cip 0M CoCt@d CA xWoK(s)d a)b fog=•t C»al tmd t•I•FltCtt•Dtaabw­Mod ao 1d!•tam a r•Mpt <br /> e rn► on <br /> Truck Deva!Number Hauler Address <br /> Business Name- <br /> Address <br /> ame- 0 b Z (Al <br /> City,Stte and Zip 6 <br /> License Plate Number State /`� I f—�n/ C� j <br /> H Ifl,0 11 H R M Carrier, <br /> I o wtsy under pen.tty bi pwpy,ander du l,"of the Sbft of Caldorni•Cts!th.'ulormeti n Po+'klad above b tru►.nd oorrad_at ad"ol%I mn*mors Cut tabiftauon of Vtls eVon—don may mmol in suspension,r—canon,or derdal of­w"of <br /> th <br /> M.W TLe I1uAer Reglma'bn pxasu*nt to P Wllc Reaouces code sem 429M.4 ma,'.*Ld in Will p01aillin w to s 25.000 P•r dmy.per viQam a aatN itzink a p.nalties up to$5.000 por vidabon per day as d—bed m Public Re—u- <br /> -42982 <br /> e—u- <br /> -42982 tAo l <br /> Drivers Name WWI, I .Driveesftnatt re— Date <br /> .. . Program <br /> 3 9 5 7115 -- �+ Pick Up. Delivery —a ITI <br /> CL D DDDD <br /> ® n <br /> 1 Hauler The Program ID I Sim Suffix DATE Facility Telephone Number <br /> mD L,J DDD-DDDDDDD <br /> C iu ❑ Whole Tire count -D welght to lbs. <br /> FF V7(Ad <br /> 8 <br /> m � � € � Volume Cubic Yds:❑Weight in Tons }�l;3t'rHauler Name Gamd <br /> U Stamp or Label OK <br /> a Address Same as Hauler <br /> Hauler Telephone Number <br /> (M!A fw l CHT�FY IT U•E6t PBIALT'I FBi?URT OF THE <br /> �)illTli�ii LAN$OF TIE STATE OF CALioftwm 71iAT THE <br /> PROVE A80M 0 TRUE AND CORAELT. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> E� — <br /> a 3 95 7115 -- B 0 . . <br /> Pick Up Delivery 0 0 Q ® ®-0 <br /> -0 I <br /> Hauler Tire Program ID I Site Suffix Facility Telephone Number <br /> � DATE <br /> Whop T� t p Weight In t�. <br /> ca <br /> aDD aao ® a � <br /> �Fadlity nese <br /> CD q 6 2 s - loll p Volume Cubic Yds.D Weight In Toms -Namet got CDr;me a1 <br /> E <br /> Hauler amt`s -Glty,S tockt - yak'rte.. The <br /> ill N � ` 000EN <br /> 1 Statitp or Labii j ` 9.5215 <br /> Hau^tel ter Tele t/+h7To�nj�ej `lNuiKnyyj�cr ■ D Address Same as Hauler. <br /> (J 0 q \ ✓. 1 1 1 C 10, L7.- <br /> t1m6i P9NLTY OP P9tAJIY'f OF T}1E <br /> 3 (N lA to LAWS OF TIE STAT.OF CNFORMU THAT Tf� <br /> Wlw1a Tiiwy2W <br /> ASOV.sT TMr <br /> q AND CORRECT. <br /> t <br /> '3957115 <br /> -- A Pick Up Delivery. <br /> D INN <br /> �. s of <br /> Hm Suffix DATFacility Telephone Number <br /> auler Tire Program ID I Site <br /> � E <br /> jf®Whole Tire Count PH&NH In, NEU <br /> Weight In Lbs. F l )5 <br /> ft <br /> `® 0 � Al Volume Cubic Yds. Weight in Tons e t <br /> 2 .Hauler Name �} <br /> l�booms' 3 ° 1 <br /> Hauler Telephone Nu be a ■ Address Sa la u er - <br /> t y ^ t AWS OF T E ATE O F CA L7Y OF THAT <br /> TH OF THE /(\..r• <br /> (t/}}I {/.{I7�/-{[}!J//'r'. (N fA rOf uyja OF THE STATE OF GtLIf-0WJG THAT THE <br /> Th") Qq�MMTM PROVIOl ABOVE M TRUE AND CORRECT. <br />