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AdOL <br /> CA Comprehensive Trip Log and Receipts ' '��NM12-12M <br /> 10002 P.O.P .Box 1269,8acrturalrto,cn 96e12-1269 <br /> , --E _ <br /> Comprehensive Tri Number <br /> • AArlt; f L ;tw f 2 <br /> ,� INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATEF 3957114 <br /> By stynlnq tht CA Compwehernty.Trip Log and Ww1K the*Wor(e)r•querrt 11W 1M Information prrNlded on this form v4d be eon•Idored rwNWrHW,propr••tary and hada secret.In aeeordene•w11h T1IM,44 CCR,EecOort <br /> 1"4.1 in"q.,It a regi t to made for 19cloo—of this Information,the CIIRM wtd coribid the alph Waj of this formal 0A addnn and tdaphrea rnahh.r prwAded on Ort form or rso•fpt. <br /> �t �•an•bLrt aei�z�'?y9nicia,n rR1a on1 Hauler Address <br /> TrucDecal Number Business Name `�0004eg9— (2-o � <br /> p K <br /> � a © ® © ® Address 2 H t L\�) <br /> City, State and Zip <br /> License Plate Number State -- Comm <br /> Q © ® ®.® � ® .® 2• . oCarrie°n ") 17(op 2— <br /> I certify under penally of perjury under the laws of the State of California that the information provided above Is two and coned.In add0on,I em a vara that falsificabon of lfiW information may recall in suspension,revocaWn,or denial of renewal of th <br /> Wast.The aedron 4295 <br /> Hauler Reg lstraIIon pursuant to PuOfc Rusowces Code spoon 42050 and may result in civil pennRles up to$25,000 per day.per vlotatlon or administrative penalties up to".W per vi t.5on per day as descried in Public Resou� <br /> Code 2' <br /> CF11 A TT�_ <br /> Driver's Name Tint D rive 8n re Date <br /> 3 957114 -- C Pik up ❑ Delivery ❑ ❑ ❑ ❑ ❑ ❑ ❑- ❑ <br /> Hauler Tire Program ID ! Site Suffix Facility Telephone Number <br /> H <br /> 13: DATE ❑❑ / ❑❑ � ❑❑ <br /> 00 w El Whole Tire Count Weight In Lbs. Facility Business <br /> ���fff _ El Volume Cubic Yds.❑Weight In Tons Name yddr.,�Q City,Mauler Name �7 �' DStams!OKJ <br /> Hauler Telephone Number a E] Address Same as Hauler <br /> (N)A far I CEiri1FY THAT UNDER PENALTY OF PERJURY OF THE <br /> whole TIMI LANE!of TM STATE OF CAIfCWM TmT THE <br /> I WOR"VM PROVIDED ABOVE M MAK AND <br /> • • 1 f - • . e • • 7F.c.1111, <br /> •• 1 . <br /> 3 9 5 7114 -- -B "Rick Up Delivery. a ® �hone Number <br /> Hauler Tire Program ID 1 SiteSuffixDATEa© � l <br /> Wel ht in Lbs.- ®" J <br /> w•�Whole Tire Count Og <br /> e° I^aclr 1 13Commer <br /> g <d cial The <br /> m , I I� Volume Cubic Yda.El Wel ht In Tana Mame d k S liCaX f <br /> city'.. A��oA'.95 <br /> S Hauler Name 215 <br /> v 1 Stamp or Label OK <br /> Hauullar Tale mono Mullttriri••h��nr .. ■ ❑ Address Same as Hauler <br /> �"- tN lA for 1 CER"re OF <br /> THAT UNDr^Tu o c4upo of PPmr Y Of TFt$ <br /> i! 1}r �pjd n�I LAMfI of TM$rAT10F CJHFORIM 1fY1T T!! <br /> Comprehensive1 •. • ores • • Program <br /> 3 9 57114 -- A Pick Up . Delivery t RED—� <br /> ❑ ❑ ® ® <br /> Hauler Tire Program ID 1 Site Suffix � Facility Telephone Number <br /> � DATEON-nu 00 Of] <br /> J <br /> / Lu ®Whole Tire Count' Weight in Lbs. <br /> o �Volume Cubic Yds. E]Welght In Tons £ da sa <br /> E Y � �f, DHaWul, <br /> �i M ,t <br /> �a p G <br /> U Name <br /> I Sty p or e <br /> Hauler Teleph tone Number E�l Addres me as afar <br /> (N/A for I CERTIFY THAT WIDER PENALTY OF PERJURY OF T@ <br /> wbole Time)' LAWS OP THE STATE OF CAL"00A THAT THE <br />