|
' Dept,of Raeouroee Reoycllno and ReoSva'. '
<br /> CA Comprehensive Trip Log and JReeipts• IOO.O2- p.O.Bo%1269,Saoramenlo OA96ST2-1P 9
<br /> AjRBC�Gl9 'Com .rehensive Tri Nu ber
<br /> �( A M P L E3' n'INSTRUCTIONS QN-BACKOF PART2 DO NOTS APLE OR DUPLIC T ay.elpinp IWe CA OomPr4henehro Tip Lett end Rocolpli the afyner(e).raquael thot(he Informallonprovidedo will ba eonelderad confidential,pmprlNary and hada■aorol,In accordance with Title,t4 COR,Bodll170et o,ecq„I!a+aGuort le matl■fordleoloeuio of lhl.lnlormdlon,OalReeyoie will aor; {he$IFner(e)oft the eddrote and btaphona numb r ptovldsd an Ihlo(ofm oReaal i.
<br /> .�; "p'�'o'j" �'y,el1`'�,��.'!`•f,� 7r��zi< ��{����.,�Ay,-� HauiarAddr� s �� f�� ►+ .,
<br /> Business Nam'_
<br /> Address y� J� �'f� I `z�i'''•'' ��s'?�3;a;yS 2.r NO tit
<br /> ,
<br /> ,� lay *'�: � -�,-ur�f T,:�. ���a;•_�- City,State and dip.
<br /> F ' , I- r IP , Y \, 1. C",►`/.'i r
<br /> C'..�Iy j; Cornmon 4l 1`@. t�
<br /> �- t ...... u.. ... ... .rJ !? fpbrr- Carrier __J
<br /> IextUyun¢arpenalty ofpe,h+q•under the laws ofthe Sl■lootCo)dotMa-0ielthelntolmtflonprovidedabove leItaandc sol,Inaddlllon,Iamawuethat falsification ofthis Information may resultInsuspension.tovodall od,ordenWol, ewntel
<br /> Or*Wa lsTu0sWer ReOL+lrellon pursuant to Publlo Reen,uces 0ode section 42000 and may result In awY pen■Iilee up It S?.6,000 par day,pe7•vfoletlon oradad,dsimilve penalties up to$5,000 per violation per deyoldescribed In Pubxe Nos out m
<br /> Cade eec_Ilon�Y0,,02//
<br /> t
<br /> Driver's Name(print) U I Driver's Signature Date �
<br /> Comprehensive1 Log Number1, Informrition Facility Tire Program1 Site Suffix
<br /> 575798 , C 1J}�j(( r� v 'r r x,.d a oa
<br /> _.:vt'_ ,'�"'?WLLL� t � -1r;7fu'�.31.�'�' '� L�1 REO
<br /> Hauler Tire Projrartii ID •/-Site: .k " -� n; _•� l�(; ' ,FW1.Ity,Telepft rtq:Number
<br /> NanTF Adtlresre..*3
<br /> Q HaUlel'Name 'u ai .h••4� ...0 :�r."n;' Cf , "tate alp(I"Lip
<br /> ` y i Stalnp or Lrilael OK
<br /> Hauler Telephone ' ber <. i j i Iy Address Same as Hauler ,n,lfa,s ,
<br /> 104
<br /> aTrV I CERTIFY THAT UNDER PEfiALTY OF PE(iJURYOPTH.
<br /> 21';"at•,:"'wr p:s'' � '', %`�•.'F ?r BfY�}a IAWB OF THE STATE OF CALIFORNIA THATTHE }
<br /> ' r_.v�•, INFORMATION PROVIDED ABOVE i6 TRUE ANDCORR[CT,.
<br /> 1 e 1 / / 1 1 f 7 1 " a I eSite Suffix
<br /> (t 'c 3<Yv 9pl`tcpj 5a ? � -'-
<br /> k t 575798 -� B �4iat� 3 rt o o a
<br /> j Vad rt o t?: mb.er.•4
<br /> Hauler Tire Piro-oraftID /•Site.Suffix ! bT
<br /> �.�!:+�;ele !�
<br /> N
<br /> � � �' � •4 •ktY;7-.':.3j"';?'',.}t�. ;�tIT�'$ ,.,s,, PP NA 1'�`� �
<br /> s�...��r,�:..r,�:,a"�b�;.�•'.,p��^-�� r'�af �.�'yi;51�'"` E(u81nFl`3J I
<br /> ;i.. .�r1' r`
<br /> Uttb�i�Ft++l
<br /> Hauler Npme 4I (r r+
<br /> B, sr'iiil�a t ti l OK
<br /> 1 -
<br /> ,t Hauler Telephone NumberI y �,;a� ,.r xR. Q Address Same as hioider anis
<br /> `� b *(. sf q'�, ., i ic'-;yt f=� ,r ;,:� ICERTIFY•THAT TINDER P.ENALTY,OFFERJURY DFTHE
<br /> 8 +w t •,jL'• x is `'a�;.f �by i'.l d(1T, .IrAYIa OFTHE STATE DF bALIFO9141I THATTHE 7
<br /> Ym!.n: ?, L.•,r_t".t~s3<'? +..�+'+S 'e�-.r'�J:G,tic,'-vSzi="+� 'ti`i :(NFORMATIONPROYIDEOA00VFIS.RUHANb CORRCCT. I r
<br /> 5 7 11
<br /> 57981 --' A 1. 'P''c
<br /> Hauler The Progrann ID,:: :rSite SuffjXl t i f '� :,!~ac%iffy Teie�honeaJuibe�
<br /> N P.IE
<br /> • - I��a 3 l i'S"Q" -i �e f i;l�'�I� ,,: +'' ,`S"
<br /> .. 4� :�` '• ,-�'� '--..,,.�.._,;• .„'' •.• 4•�� 1 ill LL, I b,� .
<br /> E. �. t`. a 011r'a.Q(Zt I d t}u n "i. J11Ci({.Q n i
<br /> $ Hauler Narna 4 A i'.: t r { _ y 5 o I. 1/Ni If
<br /> `,�''
<br /> Hauler Tele tiisne,Nuirjbe' ... ;' . ' �_;-: ; . � i - ' �lddress.s n ae auler�
<br /> ICERTIFY THAT UNDER PENALTY OF PERJURY OF THE ,-•t"'
<br /> y1�Ya,OFTHH&TAT.QP�AWFORMATHATTHE
<br /> �- — fl 6t MAiIONRNOYIpED. 90yPI0TkU0ANRcORRECT,.
<br />
|