|
' Dept,of Reeourooa Reoyplln�and Reoo�e
<br /> iib► Comprehensive Trip Log and Receipts X00.02 P.O.Box 12-126
<br /> Com rehensi�e Tri Numb. r
<br /> Gai�eQ Tale" x' .A 'M P '� 'z s. .: .-
<br /> -aNpgfGfT&a .. i- .a•"' t .-;� .-
<br /> �e+n rr(asp7(7nw INSTRUOTIONS ON RACK OF-PART 2 DO NOT TAPE.STAPLg O D.UPLIOATE ;
<br /> �Ry>rl0ning this CA COpfptobluillve Ttip Log and Receipt the signs(s):nquestthatlho fnformellat provided an[his lorm Will he.ooneldorad.oanlldanliel,proprfoloWand trddo adoral,fit accordance With TIUO,14 OCR.Sootto 11'
<br /> ,. 170Q1 el uq.,IGgrequat ll uredo for dlaoloeuro of chis Inform.{Ion,oelReeYOI►.wN oonlaot lh•.alOnorp)al lbb(arm otthe address end le(aphonc numhorproyidfd,on lhte igrnL oueoolpt.
<br /> r Hauler Address
<br /> Uus]iness Name q y.
<br /> Address.
<br /> Clty,State and zip
<br /> ( i
<br /> Common ���1VF��C.
<br /> _ .._i$_ ..._r_...:fir: ':._..�. ��•� Carrier
<br /> 100Yunder penalty olpopuryund•gal,law$Of the State ofCoA(omlalhn(IheInformation proWdedsumIsWiandcorrect.In addition,IaptawgrobstrowiloetlonotlhbMformntlonmay result Inavepombn,rovocadon,ordenial ol nevraiof
<br /> the WubTire HeWarRaglaua0pnpurcuant16Publb.ResourooeCode section 42060'ondmay result in chill penaiguupto;26,000per dw,,per.. 'In{IortM dminillralHapenaltiesupto45,000pet*Iallonpordayasd4soribedInPublic Rosowae
<br /> 0gdq 4eodon,424e2-
<br /> UAL
<br /> Driver's Name(print) Driver's Signature—
<br /> Cornlirehensive Trip Log Number Load Information Facility Tire Program ID Site suffix,
<br /> -- :C 1111"'.
<br /> '. �,` ©+} J afS `4 1 6
<br /> L.f he'{ `,w'u" };
<br /> MauierTlre.P`ro'g}atnilD'!%'&ifelSUfifiic� J "'l t j ; n l'. :r�)igNi . T6 , o iA u► Uel't
<br /> 1 E 1 ,• _
<br /> 'r ;'ir ter :i rJ -r 1
<br /> ���llEty pusinafs •}•r
<br /> iNr it3/ACldregsf
<br /> Hey ilsrNam© 7
<br /> Olt r,State r;It rip ;
<br /> i
<br /> 1. r.
<br /> Stan p )ei OK
<br /> s Ei--t Addr@ss Sane as Hauler I Naf
<br /> Ha V r 1'el`epyi4i Number i L�I -'
<br /> '� `•' a � 10ERTIFY THAT CNDER'PE ALTY OPP YOP THE
<br /> • �iL4,- }+"'-r5, LAYVSOPTH8q7ATepFCALIFORNIATRATTHE 1
<br /> ( :X �'.'��.._- nINFORMATI0N PA0V106D AE0YR1:T UE ANA OORRB4L,
<br /> Comprehensive Trip e► Number Load InformalloFacility Tire Program Site sliff ix
<br /> )
<br /> " I t
<br /> g60.54554
<br /> !Hauler Tire Pe *arn,ID.:,/_.Sitei-Sufftxi F i,(� � J�. r` lyt l);1'I s cii ty.�f i ha• a per
<br /> - � Lv rC a 1
<br /> • ::,�' iy .}t'' � r� ��,�� I"1 (•i 3:��I:j;.I%� ;�+'' ':h� E +1„{ f
<br /> jj .r � J� M ,�;�'� ;� a F, �� ,„,�a.•; Itusiiies(�' . r:; {
<br /> AC�CiirS�SS>[;1(e
<br /> a►cl eY 1 i I .
<br /> Hauler Name1217
<br /> i
<br /> l Addrvss•same as,H`a►11or
<br /> Hpuler Telephone Number y, � { s,;-.. a
<br /> y, 5 �'ur�y,�1 IOERTIFYTHATUNDER PENALTY OFPERJURYOFTHE LAWS OF THE STATE OF TI
<br /> f TE i
<br /> r.y INFORMATIONPRDYIDEDCADVERNIA BTRUEA 1IOtt4rOR9E0T. .
<br /> h e • e efelte
<br /> 1,:, a',:1 Vy ,+til. •.� A ..,!'., - y. � '�cs s' �; �f, :&:� ,,f�qq ;���J?,,G, n�;�'�`• �ah E
<br /> :���„5..:. '`T a.��l r`ly l i v•.t ti4 -1;= i� � ) y:�j�t,� ,'t� ���tJ 5� �'� '(rtY,rt!L 1441 �+1,i
<br /> i ,.i�.
<br /> :J t1 !; 1 s( .ryf :l:'S"_ t P Y �n.:,. .��...- 3•
<br /> 5°:.- + _;z'P � �,..,1,. i:�'- y �:'i'415i 1S. fs• } i
<br /> , n �t 53� y :� q_. :'mule�#i�iiy�fi'il;X thi:� .I� K W({�ti(•l !et``�l';
<br /> +f ��� i� Y 1 i,S.l ri`h �' r'?Ysc'� t� ,.,4 ur��d 1�}�'�� .3r1++ .'-{�•. �'{Fi :. � •' l
<br /> I i jsF��i - y ����T Si icy. _ ,p; �i �+�t e � 7 ) g Z - ��` +J •V y��j�' i � t���•.:L.i,';(',_5�•;: ''' i
<br /> ' �!� tJ:•a`t E F. ek_l;. 4WJ,;.,t'��. 7 :i�,,. � y � :M 6.. -,-la.'�. 1• �1,�J��L,� L,tY.0
<br />
|