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C-10b la Integrated WW.M.nag—ni So d <br /> CA Comprehensive Trip Log and Receipts 10002 P.o BOX 1259 8a—M-to,CA 95812-1259 <br /> Comprehensive Tri Number <br /> EIX A�M P L E � z 3 � � <br /> r�nile'm2` INSTRUCTIONS ON BACK OF PART 2DO NOT TAPE,STAPLE OR DUPLICATE 3249683 <br /> By <br /> ITO.jtgnel•p.. .rpuM IeMmeds bTrip <br /> luLolownd Rof.N:I.M InNbrme•lgllnonr,(eNl.nOM'MB WII Ntoe nIntefOc'1.N,eUe.lngnpeorlsildoefd Unle IbNIrem.1 M11 dNdnnn.lndOel•dle—Rd. <br /> nnplml.lo,.r p0mN,Md.,d,on Mllne loan or n1 cIenlptc <br /> codnc.—Til.,1e CCR,SeoemV <br /> Information <br /> Truck Decal Number Hauler Address <br /> �✓ <br /> Business Name �1�V F �'�`0' I C` I her6rin�� <br /> - a a a a a <br /> Address <br /> City,State and Zip p 0 • P_)GY V1 Q C �19 PrP O!Z 97H1 <br /> License Plate Number State <br /> o Common <br /> EI 1� 11- Carrier <br /> cervly uMar peneM of perjury under dre Owe o1 Ne 81e1e a Cel�lcmie Nei IM ndpm,el'ron pnvided eUova a We end mn In etldldpn Nei IelaAiuUon of Tie inlormnYm mey mull m w.penslan,nvoralbn,er deN.l b r.n.ral M N <br /> C e O TYe H. Repinnwn purwenl to Putl�c Resourres Code eacoon e296O ab mey recall h cMl pervlUee Im b S 35.000 per day.par v'gUlipn b edminisOe4n penelUa.W b 55.0110 per rglalgn per day.i ceoaloed In PUCIIc Heeourp. <br /> `°°e.emon.2929 62 <br /> /CtnrT <br /> Driver's Name print — r�fiver's Signature Date <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> 3 2496:83 -- C Pick Up ❑ Delivery0 2 © © ❑S —� <br /> m Hauler Tire Program ID ) Site SuffixDATE / / G / Facility Telephone Number <br /> w ®Whole Tire Count Weight in Lbs. © � ® a®� D❑ <br /> f a f Fa'fc�ility/Business <br /> C) t � Volume Cubic Yds.❑Weight In Tons <br /> Z9 0,e.lP.� r `I�F•G✓TAI �e PC-"/ <br /> gHauler Name L �d� Sr�e o�,a- <br /> ci /"� '/ a ��❑❑� StamGlrilfd C� <br /> Hauler Telephone Number, ■ Address Same as Hauler <br /> (N IA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> Whole TIr.•f LAWS'AFT'STATE OF CA —TNAT THE <br /> INFO0.MATIOM PROVIDED ABOVE IS TRUE AND CORRECT. !!! <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suf fix <br /> 3249683 -- B .Pick Up Delivery �/ ®—a <br /> m Hauler Tire Program ID / Site Suffix DATE f / / J Facility Telephone Number <br /> _ <br /> TO a ®Whole Tire Count Weight In Lbs. <br /> ID <br /> fie ' , <br /> 0 3 3 G Volume Cubic Yds.❑Weight in Tons N'ne res�77s,mm�r// <br /> 11 <br /> E <br /> Hauler Name Cly' <br /> N EEEnHn4loU fStam rCsord 30 y� _ <br /> Hauler Telephone Number ■ ❑ Address Same as Hauler n„f,,, <br /> �` / (N(A for I CERTIFY TNAT UNDER PENALTY OF PERJURY OF THE <br /> J'`p /�77 Who1.Tire.) 1A 8 OF THE STATE OF CALIFORNIA THAT THE i/ <br /> INFORMATION RROVIDEO ABOVE I8 TRUE AND CORRECT <br /> Comprehensive • •• . • Program <br /> 3249683 -- .A *2''Pick Up []:Delivery <br /> Hauler Tire Program ID I Site Suffix c Facility Telephone Number <br /> 41 <br /> DATE ❑� / as , ❑❑ <br /> N © ❑ -❑o❑'❑❑ ❑ro <br /> ICO w ©Whole Tire Count Weight in Lbs.CL /� �� �� - <br /> f ❑ ❑ mt2 `r 'n�e7�61 `�sss LSC, <br /> EQ 0 3�o Volume Cubic Yds. Weight In Tons rL� <br /> E Hauler Name C�� "� �hG <br /> a a❑❑❑❑a ❑� a� <br /> U <br /> Stam�l�b <br /> Hauler Telephone Number � ■ � Address Same as'Hauler <br /> r/e(/ (N IA for I CERTIFY THAT UNDER VENALTY OF PERJURY OF THE ^� <br /> G!J <br /> Who O Tlree) _5 OF THE STATE Of CAIJFORN4 TNAT THE //✓�// <br /> INFORMATION VROVIOEC ABOVE IS TRUE AND CORRECT. <br />