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May, 29. 2013 11 : 1 11 AM No, 8883 P, 2 <br /> Toll Free J66-806=0600 ;/ www:ci'wrriki c ,9V/Tires/. <br /> • r` California InlIbe led Waele'MenttyenTet i eoard <br /> CA Comprehensive•Trip Log and Receipts 10002 P_O.Boz'1259}daorarne 10,CA'96612=1259. <br /> X A l? -. � Corri �ehensive Tri number <br /> V'V'Yl''' • INSTRUCTIONS ON BACK OF PART 2 DD NOT TArP�r SYA�LE Oft DUPLICATE <br /> cnlrsle zdd ry c.l <br /> By signlna lhl:CA Compeohanslva Trip Loa and Recelp4(h•ergnerte)regtleat OW lh+i„fo.m+tion provided on lhta form will 0e considered eonfIdenlla),proprietary and bade eecrer,In vAd,T7Jo,1e CCR,aa,Ce. <br /> 17041 at aeq.,IF s rcgveet le­3a r+r d;aelosura of this Infor mxUon,the CI1VM9 V411 eonlaul the•taner(e)*Wilk form•t the•ddr4aa•nd{•laphona•AumO•r provldad on loU Ic rtn of recerpr.. <br /> Hauler Address <br /> E3tisirie's$ Name <br /> L; Address <br /> 1_ City, State and Zip s . .. <br /> /..�I <br /> 0 Garrper <br /> I cemry undar panmry of paqurf under Ne laws of the Stew of Cielilo,ota tlm1 the fnformi iorl provided ahova la Wo and correct In addlJon,t am aware alai(atslllcallon of(hid InFNma(on ro•y ree.,IL i,laegpaf.atoll�(aYerplfan,or danlal o/ranowal of <br /> W.04 Tirs Heuler Re9'errsrion perdoanl to Pucllo Resources Cale aectlon A29Q0 and way resullln&1 penal6eB u9 In 9 25.x00 poi Qay,par vlor.Uan of a Iolslia Wi penalties up 10$3,000 per vloladcn per day as da aeACed in Pulfso Resources <br /> C 16 eecCon 42902 ..• a � ,t".• .��•'. - _... J <br /> Driver's Name rtnt) afe T <br /> i, rivets J., <br /> • 0 M 71t Al4 <br /> 3:248589 In -- C <br /> }jauler Tire Program ID / Site Suffix ] Facility TelephonA Number <br /> [J, <br /> cit y f tis t�tiss C��t('1r�1 Uu�fey <br /> al <br /> Hauler Tie <br /> City tate a)�412'il) <br /> �t� Stamp QrLa4e.I OK <br /> Hauler telephone (VutnberAddress.Sane as Hauler <br /> ©lephrn,ryr> <br /> )CERTIFY THAT UNOCR PrHALTY OF PERJURY OF THELAWS OF THE 7 <br /> ,/�`/ �( r`,�� r ✓ IA TKAT THE <br /> eWPORMATTO;FROYIQC <br /> OF CALVE RNTRUE ANO CORRECT ' . <br /> • I - e • e e e l a • •• 1 <br /> 3248589 <br /> Hau[er Tire Program ID / Site Suffix D FaciliEy Tele�ll0 a IN mer,, <br /> - 3- C,7 <br /> ora oaoaoa , <br /> R75 <br /> (�acilit Business r X (v r <br /> t <br /> Name/Address f c <br /> Hauler ams City, State end Zip % J (/dL�Gru <br /> tc" Stamp 4r I.ittiDl OK V <br /> Haulor Telephone Number' Address Same as Flouter r�ruars J <br /> I CERTIFY TMAY UNDER PENALTY QF PERJURY OF THE <br /> LAM OF Ttir 6YATE OF CALIFORNIA THAT THE <br /> tAnVICIED ABOVE IB TRUE AILD CORRECT. <br /> 3248589 <br /> Hauler Tire Program ID / Site suffix Facility Telephone Number <br /> ooa ®Qa a � <br /> �•� �l — r `ac.%lity.F.itisinesb /�/��i,< W1 Ur<SI'�'� <br /> r ) f N�tT)FjAddresr 16,U�� <br /> Hauler N ins City,State and dip l 1 <br /> .9tatnp or Label OK � <br /> Hauler telephone Number <br /> (/ 6� 0'Address Same as Hauler <br />