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Glifomla Inbpfat.d W4a1.Man.e..Rf Board <br /> CA Comprehensive Trip Log and Receipts 10002 P.O.Box <br /> 1259,SacT.roant.,CA p5B1:-175p <br /> E X AjM P L E 1 2 3 Comprehensive Tri Number <br /> INSTRUCTIONS ON BACK OF PART 2 DO NOT-TAPE,STAPLE OR DUPLICATE 3249692 <br /> ByMpnlnp NI)G CempnMnalY.TMP Log and RPmIK dn.I.n.Ral.q...ton NI NNormaUm pwld.d on W form WII M conYd.TW eaRRanllµp.Pr1.un"-d.Maµ-In-.—WIN TW,N CCR.a.Non <br /> 1TOa1 al W..N.r.Rn.M I.mad.Tor di.cbwn M ad)IMPr U.n.12H CIWMR w11I coR t tM M9n.r(.I of N,form at ft addnw aM Mop—numMr pmNd an tel,form w r IPL <br /> V.ehlc a In orma ion <br /> Truck Decal Number <br /> Hauler Address I�7�WJE �,�, /_c r,e, ( h c,1 c � <br /> t I � <br /> �` <br /> ® � — <br /> EMOP BusinessName s Address: �G �� O <br /> City,State and Zip <br /> License Plate Number Stale <br /> NPH <br /> © D © y/ ©H ❑ Carr e rn I ffi <br /> I coney urd.r p.nally of pawn-N'N'IM Iowa a1 do stat.Of Calif M'IMI Ma N—UM pray aEov.H e and caned m ad 1—.lam aware Uvt hI.lATalian of INA Mfamatbn may nsup N wpal ..-0..or de W d r—ar_w.1 <br /> Warta TV.H-W R.platra6on N-1 b PW Ilc Re—Cade wdan)T9E0 6rM m.y n)alt in clvY penNli.s W to$25.0DO per day,per Nola a Wminm.Uv pe-W.W to$5.000 P.Ndedan par day w ft— lir PW I.R— <br /> Code M tion 42962 l Q <br /> JcTkrr L— �/ <br /> Driver's Name(print) Driver's Signature Date <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix1 <br /> 3249692 _- `' _]�]Pick Up Delivery <br /> Hauler Tire Program ID '/'Site SuffixDATE / / C� Facility Telephone Number <br /> _ �ooaDD �, o _ ss � � /, � <br /> ww Whole Tire Count 11 Weight In Lbs. ❑ ❑.❑ <br /> f F ility B_u}siness <br /> y i G G e� 3 3 0. Volume Cubic 1,®r �A& '0?srs' <br /> o Hauler Name C61e <br /> ! a DDDDD ODeCP cG• <br /> Stampor .atpglAl9 <br /> Hauler Telephone Number Addrss Same as.Ha/u�lner <br /> i <br /> IN/A/Of I CERTIFY THATUNDERO PENALTY OF PERJURY EO TME <br /> uWg OF TME STATE OF CALIFORNIA THAT THE �_+•r / <br /> INFORMATON PROVIOEO ABOVE 19 TRUE ANO CORRECT.. <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 3249692 -' BJ Pick Up Delivery a /I Lj a fl R 0-H ❑ <br /> r Hauler Tire Program,ID I Site Suffix Facility Telephone Number <br /> DATE / �❑ / <br /> c ww []Whole Tire Count Weight in Lbs:o' r �' CI �. �• (' a O <br /> m lC 1.0 -j � 3. 10.11. O Volume Cubic Yds. Weight in Tons N melAddresS <br /> Ec7o� Hauler Name <br /> .. i/ af DDDDD DDC `' �te arid.�iprir/ S 9� dZ <br /> q53s� <br /> /StatrI`p~or (er0k'4oC/ J <br /> Hauler Telephone Number <br /> Address Same as Hauler ,refill. <br /> �... IN IA for I CERTIFY TUT UNDER PENALTY OF PERJURY OF THE /) <br /> IS 7 what*Tin.) LA OF THE STAN OF CALIFORNIA THAT THE <br /> MFORMATON PROVIDEO ABOVE IS TRUE AMO CORRECT. J/ <br /> Comprehensive I Log Number Load Information Facility Tire Program ID <br /> 324969-2 . _.:A' z Pick Up <br /> ElDeliveryMMERM-a a <br /> — FacilityTele hone Number <br /> Hauler Tire Program ID / Site Suffix l p <br /> DATE ❑D / ©� / D❑. <br /> ❑ ea❑�oD© <br /> M w ®Whole Tire Count ❑Weight In Lbs. <br /> n Fa li B I ss <br /> I S? p <br /> m I O.0 3161 :31 C1 / ❑Volume Cubic Yds. Weight in Tons NamelAddre S G 4 U <br /> E Hauler Name Cit,jSlz(te,,V7jp,./pL/ nJ2, <br /> Stamp or.Laabel OK � <br /> Hauler Telephone Number DDD■D D ❑ Addr�ss�amVe;9 HauTe r Inrtlaf9 <br /> 7 (N IA for I CERTR THAT UNDER PENALTY OF PERJURY Of TME <br /> I YYl ala Tln.) LAWS OF THE STATE OF CALIFORNA THAT THE <br /> INFORMATION PROVIDED ABOVE 13 TRUE ANo. <br />