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<br /> CA Comprehensive Trip Log and Receipts Dept,of 1259,Smeinto,Recycling '00012 ovary
<br /> 10002 P,o.6oxi25e,stigramanto,cA635tz-1259 1
<br /> ' r Com zrehensive T
<br /> Number C81B6 cler X A M p L Ej [112-1:3
<br /> .9 to
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<br /> . crfeera;ro�anorINSTRUCTIONS ON BACK OP PART 2 DO NOT'TAPE,STAPLE OR DUPLICATE -• r!.c/?r,..• �
<br /> I by■Igniho Qua OA Oomprahonalve lHp Lou and Reoelph 1116elg0er(ef toquoal that the tnformstlonprovidod on this formwIll beoanafdared uonlldonliel,propdularyand trade aecfal:In 000afdaaoo with Tltla,l4 OCR,5 011im
<br /> 170.11.at tq,.II a squeal le mode for disclosure of Ude Information,Celpaoyclo wUl contact Iho slgnor(aI o,thio lomm et tho addrose And lolaphono numberp a deq on this form or roaelpt• I
<br /> Hauler Address
<br /> Business Name '
<br /> .....+.j G Address
<br /> •C�'` L'.J; 11' City,State and Zip
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<br /> I<tnvyuilgetpkholyolpoijuryund$r Ulolawboflha Slate of California that the Information pmddad above Is We and treat.In addlildn,Iam avisre that faWsllicatldn of ihlslnlormalion to suspondon,rovooetlon,ordoMal ofrotowal of
<br /> IhoWAS1411ro Hauler Registration polwantio publ'b gesburcae Codesootlan 42ti60 and maynsultN�l��pandtloa up la$2S,o00 per day,per vlohtlon or admin. cillo E .rviaialian par day as described In PubOo Resource
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<br /> DriverldName(print) Dri 's Signature Date
<br /> Fiea e e . e- a s a a s r Site SuffiT,
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<br /> Stamp or Lo0of C)K
<br /> ' 1-!puler Tolephollo NUMI)el' M Adcir`esa Same as t laulor nrrmra
<br /> "' {N/A=for•i ICERTIFY THATUNDER PENALTY OF PERJURY OF TNd
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<br /> LU x Whole.Tire Count' D Weight in LISs r
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<br /> Volurne;CHhiQYds L_ Weight in Volts( i�2,'�t't7�r/�A dreM
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<br /> }.,f Mauler Name
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<br /> % 1.7.;'j Address 5an•re as Mauler
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<br /> rin / (NfA(�;, r: ICERTIFYTHATUNDERP�NALT$OFPLRJURy OF THE
<br /> 907-76t;!? ` 0-7 �C �` ?-, �z l jolo7rls).'i LAWS OF THE STATE OF CALIFORNIA THAT TH6
<br /> �1 INFORM 710 OVIOED AEOVE In TRUE NDCORREQT
<br /> a s e e e^ s s a r I s — Program
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<br /> t �_ �'`• yd>"}'a'+*"`_ �• r5 �3�= `9 LAWS OFTHE 6TATQOFCALIFORNIA 78
<br /> ATTHE
<br /> - ._� / ��•• .(�Y .•7 7 � -''�'��,L�� �' ,INFORMA710NpR0VjDEb I.BOVE IBTRUEANO.QORRECT.
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