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-- Calilomla Integral.Warta Nam ement Boats <br /> CA Comprehensive Trip Log and Receipts 1ooli2 P.O.Box 1259,SaDramanlo,CA9591Y-1259 <br /> kX A M P L Ej �1112131 Comprehensive Trip Number. <br /> awu9M 109°s11NSTRUCTIONS ON BACK OF.PART 2 DO NOT TAPE:STAPLE OR DUPLICATE <br /> 3745215 <br /> BY.19nIrp W.CA C—,n*henWs Tdp Log"R—IpL the el9ner(a)nNl-el that the Inlorm•Uon proNded on ml•form Me W mnebered ce ,nlxl,Praprl•Mry end Inde a•p.t In a Drderee ele,Tide,14 CCN•aeollor, <br /> 17011 Id ee9..e•req_1•made to, <br /> dteC,_d We In onnetlm,B1e CIWMB ar10 molal aro-19-0)al mla I—M ma add—end telephone m.naer provided on this lona or r Mpl ' <br /> Hauler Address <br /> Truck Decal Number ' <br /> >Business Name <br /> U <br /> p D G p Address 3`�S-Sc� Tl. �EIJTE 12• FET <br /> 11 M P ET H ® City,State and Zip 'V'j,�K-E-0 ti e! _ 5 v�j <br /> Licensee Plate Number State <br /> ®2 ® -.©3 . o Co <br /> Carrie rn ! <br /> —_ ._I mnih„roar p.nelly or pw)ury uroer de tewa a ms stns m celHomle mm me S,TA„nmm awldw.bow a vu•end mrraG.In.ddmm:I am aware mel teNidralbn�f ms mr d-n u+•u.c "un:-r.wuudr�.u anloi oI l.nwr:i-m uK --� <br /> 'W.I.r Hamer R,Iev.don wnu.m m weiK Ree —code asadon 42960—..y-0.n dw peneldse..$25.000 per do,.",.laeum or•dminnmdM pnel9e•up m$5`D30, per waetron pe,aay A.eesmeed m public N..ou,c.d <br /> Code aedion 42952 <br /> AlA� 7 09;103071902 <br /> rived;s Name(print — rI�D vers Slynature. Date f <br /> Comprehensive .. Number LoadProgram <br /> 3745215 -- C Pick Up Delivery: <br /> °7 Hauler Tire Program ID / Site Suffix DATE / Facility Telephone Number <br /> 9 1 SII^j��I4 <br /> W / ® <br /> ❑Whole Tire Count1:1 Weight in Lbs. <br /> � - a I Facility Business I <br /> `` ` El Volume Cubic Yds. Weight in Tons Na P' <br /> E City��'Q300 NE'1NPORT RD <br /> o e�W-PRODUCTS,INC. <br /> Hauler Name <br /> ) I- BALD %8&4855� <br /> - /— r 7 __ ®_ © Stamp Or l y <br /> Telephone Number a Address Same as Hauler tnl m. J <br /> I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE VL <br /> (N/A IOr UM OF THE STATE OF CALIFORNIA THAT THE(� wnolanres) <br /> INFORMATION PROVIOEL ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip •• Number • • InformationProgramS Site SuffixFI <br /> 3745215 -- B Ll Pick Up ® Delivery <br /> m Hauler Tire Site Suffix ID Program / Facility Telephone Number I <br /> g DATE <br /> Whole Tire Count Welght.ln Lbs. EONi <br /> 1 Facility Business'11 101 <br /> E El Volume Cubic Yds.®Weight In Tons Namrd6VdEWBY-PRODUCTS,INC. <br /> o Hauler Name 7C Cityt'13000(NEWPORT RD. <br /> � � � �� !� � BALLICO,CA 95303 1 a Bog <br /> Stamp or LALLIC gCA953 J_j Hauler Telephone Number- Q-.Address Same as Hauler.,I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE i <br /> '1 V O \ P� Whole orae) UVI9 OF THE STATE OF CALIFORNIA THAT THE <br /> l INFORMATION PROVIDED ABOVE 19 TRUE ANO CORRECT. <br /> Comprehensive •- e <br /> 37452.15 -- A Pickup Delivery a fl ID <br /> © m7 (� <br /> Hauler The Program ID / Site Suffix DATE Facility Telephone Number lJ <br /> m g OF01 <br /> ®® [dN <br /> io w OW hole.Tire Count aWeight in Lbs. ' <br /> o. Facili4GOLDEN,BY-PRODUCTS,INC. <br /> a`r Q ❑Volume Cubic Yds. Weight In Tons Name/Aa3000 NEWPORT RD I <br /> E Hauler Name City,State eBALIJCO,CA 95303 \' i <br /> U O"1- 9 3 q- r r �l �- ~ Stamp or Label OK <br /> Hauler Telephone Number <br /> _j <br /> f <br /> Address Same as Hauler Intuat: <br /> l I CERTIFY THAT UNDER PENALTY OF PENJURY OF TME <br /> (NIA lo! uWa OF TNN STATE OF CAUTORNIA THAT TNf <br /> Whole T1TBB) INFORMATION PROVIDED ABOVE Is TRUE AND CORRECT. i <br />