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r <br /> Dept.of Rasouraos Rooyaiing and ROOovary ' <br /> to CA Comprehen. ive Trip Log and Receipts 10002 P.O.Box 1269,SooraRmento,OA96012-126¢ <br /> Ca�NeC��le E X A M P L E 1 2 3 Com rehensive Tri Number <br /> cene`ird►�wnlia�IN$TRUCTIONS ON BACK OF PART 2 DO O PE STAPLE PLE O PIC E <br /> ( Dy daring this OA Comprehensive Trip Lou and Re-slpl,th signori-)request that the Into Mond,ovided or this form will bo come ldered'on <br /> lidvnlld,pTOP <br /> rietary and ladp worpl.In a.rdance with Title,14 CON,6-otlon <br /> '1704foleeq.,Ilarequaatlamadolordbalmureolthis Into mptlon,OalR-oyebwlllcaMpotlMlbner(e):o1111form atAhrlddfnrpndkNphonlRunt6pr raAdadonthletormerreoelpt. <br /> 41,61;1 11 fitzrom at 16 7 <br /> iruv =p$o hhluh bar a hiauler Adc ress <br /> Budness Name <br /> Addreas <br /> a �. �, © - city,State Id Zip <br /> LlcarigS..lata;Numb'r ) State <br /> ❑� Commol <br /> :..� `LJ J Carrier _ <br /> IIMdWWlf{ydeTalpprfuryunderthL,ol�awsofthoState01001omlathat tha1nfounatlenprovided abovo10IM0 doorreol.InaddhIgi.Ism swerothat ledenlalofran�sesvfalofnAHonsthlyrmtoMilo RasouroisCode secdon42840and may rmuntn�radlnlimopa45,000par vloal nperdayatdsicdbedInPublbResource <br /> / �L@ <br /> Oases bo <br /> Driver's ame(print) — Driv_vvfinature Date <br /> e e e 1 e ; a e. 1 - e • 1f <br /> �- <br /> 5757 6 9 9 <br /> ---- 61 ❑ Pick up ❑ Deliyel'y <br /> 4 <br /> a <br /> Facility Telephone Number <br /> HaulerTlre Program ID / Site Suffix i <br /> ATE ❑❑ / C� —1.;' <br /> l w,❑ V� al< silo C tint ❑ yht In Lh,,, <br /> Ice. ❑ olurneCubic 64 611 11TOnS; id.nrle/Ft:fdi'caas; <br /> Pity,.13-ho And V11) <br /> ,.I Hauler Name <br /> rt r f<miij or l._01)I OK � <br /> ;: w3 ❑ Address Same a3 Hauler it)a s <br /> Hauler Telephone Number <br /> CERTIFYTHAT UNDER PENALTY OPPERJURY OF THE <br /> ' 'lDlegl I�s�.rS LAWS OF THE STATE OF CALIFORNIATNAT THE <br /> f _ -At• n"2FS'(+.`-.'k ba INFOR6IAMON PROVIDED ABOVE 15 THUS AND CORRECT. <br /> r 7- <br /> 1 1 I e 1 t 1 { I ce <br /> �r � aaoo _ a Q <br /> Pick Up I Delivery S �- <br /> �ti 5757699 -- B ❑ i <br /> Hauler Tire Program ID '/ Site Suffix Facility Tel.®phone Number <br /> DATC � � <br /> ' LU dlole Tiro Gaunt ❑,Wglght in Lbs.,. MY M10 <br /> 1 U ❑V0lurne Cub(c 4dE), ❑ wel{�ht In;TUnsi �N. n \c.rirt.. .t`��1 i <br /> E <br /> - s1•tz j s.?s��('J cr�(i^}??tel. �' -l��i" <br /> o. Hauler Name , /^ 1 <br /> H Fu ler Telephone Number ■ t ❑ Address Same as Halder ,r a - <br /> "' Ii'UA p. I OEATIFYTNAT UNDER PENALTY OF PERJURY OF THE <br /> 1N1101d T1ie8}Y: LAWS OF VEI STATE OF CALIFORNIA THATTHE A, c` <br /> .INFORh1ATlON PROVIDEp AEOVEIBTRUE AND CORRECT. <br /> f t'' Log I. t InformationProgram <br /> 5757699 -" r, a � i �e LJ.4 -.ins ❑ ' �;w. ':�,• <br /> 3 t 3 Fadiiltyft'elep 'dne•Number <br /> Hauler Tire Program ID / Sitef S lffix' <br /> P KEE I <br /> f ., r, '� , ��. j _+ it+�'` =Ill i.,. • <br /> s 1, V cJ f �� '�•� © ( L o t1 B � r� „ :� .���1T� $Q � a.ri-,l, r e M <br /> Hauler!NDnq`r <br /> tiler Te) hone umber I t [ Adt1'erss pipe a Fl�uler <br /> Ha a) „: /rituals <br /> i�i`:S��RTIFVYHAr�11NDERPENALttOFPERJUItY.OF•1Hg <br /> AALIFORMATHATTHIF �. <br /> PROVIDcD'ADOVE Is TRUE'AND. ORREOL <br />