I
<br /> Dept:of R soutlaea Ro'oyoling and RaooYery
<br /> CA Comprehensive Trip Log and Receipts 710.002 po.>30><, 5s, aarampntu,oAe5D12-12¢8
<br /> 'aIiECyClE ' X A'M P l E 1 2 3• ■ caNO�rq ens( Tri M'N 1.
<br /> CA,ryr'so`p/to INSTRUCTIONS ON B'ACK.pF PART 2 DO NOT B .STAP/E R':l).UPI_ICA•E i 'n �� sA 11 # '1. „>'
<br /> air 1aU.tr°r' !
<br /> r Py 6lONn{I Ih1a CA gomprahonslvo Mp Lap antlfiecelpt,the 11.11 r,Irlgooit ll!at.t Information Provided onthlotorm will ho cgnild�lf'd onlldantlpl,proprlolary:ond lroda+aore6!neocor"an'ce'Vt 11171119,140oR,9adllon
<br /> (` 7
<br /> -110411 at Mq.,lfaagumlla ntado fotdlsplosuroallhlt lnformntlan,OalRooyQle'wlll oontaotlheel9n•rp)oIIhI (ormatthoaddreee bn dol phoAanumberprovldpdon IN larm orreoa pl. I V
<br /> - J far at n r
<br /> F+s r..lxvr,rt'v. .. 1''F 5 •TL J i�.isa � � i I I
<br /> i' Sr a` P � �� Hauler Address
<br /> gusiness Name
<br /> •'•° r, � fi � a `�,g;,�a Address 2 Z.ec)
<br /> City,State and zip
<br /> t
<br /> Corp
<br /> ,;ctGaYrior
<br /> .1 ceNyunder pd`u lyplpoilury under the laws el tho Sate of Cal(omta that the Intofmtllon provided above Is Into and cefrool.In addltlon,Iam&wIto that fabillcallon of this lnformatlonm ot,Ina pxnsipn(owont!on,or dental ofran owA of 1
<br /> the Waeio The Hauler R60151ndldn pur611pt to M1 to Resoureie Codo sootion 429601 ontl lney result In civilpenilgosuptoS26,000pord+y,'potvfo Alton of adminl epen+llloe' p viola Iw par Al
<br /> desar0tedmPbhpo Raaouro6t i
<br /> 'Coda eed0on 42ea2
<br /> Driver's Name(print) Dr1ve Iasi
<br /> gnature Date 1
<br /> cya - e•
<br /> -6'2 9 101101
<br /> ` I z Y'. ,•,K�, rer I I W a 0
<br /> [t JGil y *.Ktd IF`fi Jig
<br /> ��vs
<br /> FlaulorTire Program t.D 7' Sife:S'IJ{f( t, .:9x�4�''•" IM'� ;;' S � �. !�aGjl(ty feient?o.n.e' um�er:
<br /> }a �Y � p
<br /> ��� .(,i f 'ifi.�i•'`r� ii� .�:�`� _ � Da i s.�51 .,.. !& yC '.��i;,'`- '++l 1' (
<br /> {'�,l M� �nt•, -;� � Yit'.<, err r,,,-, �,�! �: �:�
<br /> €� .•1J.).7t 5"l � {' :e � �li`-7�}/�� 1 l.lu•'h ...,.i',:s: •.,;, -,: i
<br /> , ,.•� "�#a'' ��"�-�;��a �.:.��" - ��` Faallity dait3,ts(ilt�3
<br /> tu> i " Nettie%I1c s
<br /> Hu[or Naio A?-�t��t::�:���� a r ,�`• ;~' � � �vt
<br /> f,•''-t,'. °.?•�V`r' r. r&' +iY+'rC.{i7 d,•it.' .? ai. l�, tJl ,tif}7.e'an:!
<br /> a
<br /> isi o
<br /> Stlnp o �,.fll)ei 0 G
<br /> � ,Hauler Tel`ep torte' er il;,'tl�i , !I,.+i sf(, _: _ACiGiY` u all El Ei��IQr Inttiota
<br /> ?�<l A.(,'iih .a._+•-.'..- "}..'8'�'y�' �• <@•i'{ :j CERTIFY IHAT-UP!tlER PENAL'f14FP RJURY OF 7HE
<br /> tr":x �p�'+ti�i,:':r;J`d~a;�.:!y!..:., ..;i''<:. `•i;''T ^���. "'`.�wn-r Bt Irga):.s'.� ,4AW3 OF THE S*TE OF OALIFQ INIA HAT TH� ,+�
<br /> i
<br /> ( -��„-t...:'♦;;}t?z:-.;.i INF.OR6IATIONi!ROVIOEb A80VE'19 TR 6 AND CORRECT
<br /> 1Comprehensive Trip�oq Number Load Information Facility Tire Program ID
<br /> 605462,9
<br /> iii •a- :t p {."pK��t s �((j Y' v
<br /> I' ? Hauler The Peb raWlD'r/:;Site:S01 ' ; t�`� !_t.;i', .t. �PI'..f- ' 'D
<br /> cit tY;Te1 pl�gge.Hurt}.'e,r:>. � `
<br /> t 1 ;iw= zm r l
<br /> _
<br /> ► ,t � 8 TA Pl §- 'rsi J.frill
<br /> •
<br /> Srf i v,,�-.,',.,.,s$e, i
<br /> �?. �''1'l'.,;' r dpMt t+ , c l o .1 I,y Qns :(.all
<br /> A(d( Vis: i
<br /> ;y„ *iF..?hahr?:,.; 11',c-.a Y+,r d'1 .2 •.1 , sk--In d�f.,S{.{�'!'p 6�*�1,.1•,� I
<br /> o- Haulsr-Natno +
<br /> _.!.'_lt.l '.tl.}i� !'l1 '•' '7 j'.y� {�;{ G,4f-
<br /> r��
<br /> I Iauler Tela kl'aiie Nutpber 1 4. I i rt _ I [� Address Same a Haulor
<br /> aCli;-'�,1'.('A^`••1'i. -�'F""7 "sir rF. ,
<br /> csir!`G%>}} �a ,!, _T,:•'i��,,l,}.'tq'%; ; a`*R �I OFATIRYTHATUNOER PENAL7�OFP RJURY'FTHE ''.f:'.•- r
<br /> :f�f'F�:,•.'s I P
<br /> �5 {.�.Ct/. !^"." F/ !! ,Uj "+Lk•a'a�ii t`•�y,':{�`+t1 1�'n;i;.(ni'j"`'�}�"t 5"h",.�,;.t�r, if J l,'q�6�r:1. •LAW90F•TN4;STA19 OF:liALIFO IA HATU i
<br /> .lNFOl1MA710N FN0 gDEd A60�E 18.7RUNANO'OOtiR O,
<br /> _ l
<br /> iComprehensive Trip Log NumberLoad s a' er e '1 Site Suffix
<br /> nyrT
<br /> tinillcl .I"e l Yocll';lin lU i ��TO S!ifflyyi "' ,f^ti �" ' Ml f)�� j��djr1�+'j �9�. ,�y��)Df! f�� •,4., !.
<br /> 1711-91-2; ! !� 1 )
<br /> k ;rKyja°I ita,�-';] •T Plf
<br /> {•Ctl,_.I:.}6S.]ifil',�t1
<br /> nttt;- ,-!='.
<br /> :�!t. :it'll?Cj>h�`''it�' l<,, +t •,fl'.t•-„^v< �'` j_" �._` •.8:_. � R t 'aS;,r.r:. ?:.L.'..
<br /> g' .� .W-lir "t i ` t _ � �J �`i'����-.� L"��.1 "i�ai! •rr;:'; �'
<br /> =!• _ r!>;•,• f} '/, .-r, _-� ,r� Ser :a•.La. ..,?Il,ala^'' ::`i�' _ i{ai'
<br /> - '�ti:..s;;,. Wi -?,ice _+. r� r_,.,. rr- r; ,I ,.i;='•',,,•,::•
<br /> j�'� if I,��ti14.v��i��'4:rTr�i.'i��'*�G"�::�a �"�i�� r 43 �-k. N.4'p} I r'-1 I!lr _ �. W!'e y i�- ';S:� C•� a s'.., i'•q. 5r�•'� fg,�'
<br /> 1 ! ''. �-�I�i+iYF�..mac-.�'S:�EST;t_�•a,- ,s��A��� �t(.��� :t'�� .},Fid !�P t� J'_�r�� p'l�s�f5.4' 'r'3:t':.' Pul�r,c_+ �:�.�(•0"3�', c• .:;»i•
<br /> _ .,L"rn,•a*ri,,S WIN,
<br /> ' �),1a^C {a'fi:M� ':'�`•- I ,���•��x'•1 r''�F^.1'. x! 'i�yf Sk w..+ rv�i�'-`li,..F.i:: �,�-' /!,• -•)
<br /> i-laula iTe�e�jl�o ,514 mbar ;t+J
<br /> r rv'k)fY- tb HI, ?cr }�I
<br /> l )-=�P 'r (;' C ' > T _ C;NkbaA6u Io�HHit41 kAVk7�tA0FfAH o �.
<br /> -,.:.... � _ ., :._. >.uvn.-1-•-. .r..f.. - „':� aee•rt+•'.vMla.. .w.uc.ew+u�n— �. .-.. ..._..-.. _-. .
<br />
|