|
Y/I' �b•t70ii1 ' !Clfl•L71Elal`i71Y:17 '1!f1�[') I5®��77��� ��t�tqr��f 3 I r I �jFF?y., �r.� am y. r.r,+.€{ }.. ....9.
<br /> 6"
<br /> l1t&fv9':9� 2a'1269:
<br /> 'R�IR�a�y'�Ir� � •X•: A �°iP ;� .� 1 2 3 :.... ._. ..:y .' .
<br /> Number
<br /> amrof GNwNa f �, y'r{. C fS= Jyv;'itV /•.
<br /> cdBecnTe2Wpnd1II+ISTRUCTIONS OM BACK OPPART 2 DO:NOT TAPE,ST6►PLE O DUPL'CATS `� . 7 'r ' �.;'. ; `rh' '}z
<br /> �:
<br /> $yaipnlnp IhIt CA CompnhamWe Trip Lop end Rao•ipl,ih.rlpn.r(e)request thatch.Inferm.lton proNda,,on lhb form will be oonaldend oo ldmllel,proprbtary end Indo seorat.In aavordenss with Tlliv,141708,$Dolton
<br /> 17041 al uq:,If a nqussl b made lordl-otv-un of this Inlamlatlan,OalReoyole Wi11 cantiot.the signer(-)of this form at the address and telephone number provided on this form or rso•Ipt.
<br /> I\ , 4 ' 'e, L:: ` ��„c•� 4-;?,.�7•;,,-,: :.:.:,,,.i.,.�,.•:;, ,:,••
<br /> Hauler Addrebs ,
<br /> Business Name
<br /> Address East Bay Tire Company
<br /> city,State and Zip
<br /> 2200 Huntington Dr
<br /> Common
<br /> Carrier.
<br /> I asrafy uddarpen-Ily of p04 under the law• Stab of Cellfumle that the InfWmillon provided above ts tiui ind aorrssL In adddion,Ism aware that labltoatlon of IMs Info I on msy mu"in ss-p4nslon,revcoattort,or dental of r rlowal of '
<br /> the Wesla The H•ulw Re plelrelbapur•uan Pubt Resources Coda InIlon 42 and may result M'dvh penelll44 up to$25,000 per dry,pare or adminlsUallva penalllea to X000 psr abfslbn per d-y ea deacdb•d In Pub Resource
<br /> Cada seollon 42842
<br /> Rfiver's Narme: pi.int - Driver's Sigilatur e j
<br /> Comprehen ive Trip Log
<br /> 0765
<br /> v i iF.ti i',
<br /> Hauler Tire Program11) / Site Suffix Facility Telephone Number
<br /> �rf Z LJ LJ LJ
<br /> 'i
<br /> :916 7111`9 Ut1t'.f�
<br /> t} ',� , ;I , , f-ar.:illty(3usina•^s
<br /> re i ,. .+:, ]`1/o1Um�C,upl>;jYits,.`; � Vel�kltifl�6i1 IVtllue/ACi[1t'�'�n-5G Bay TireCOfYtPON
<br /> } Hauler Name , I ;t Gitr,tSiatt,,and 7-i Q}{C1Cr1S RV4rr1UG'
<br /> U r SF.arnp or I_11,1521(*I;clmentdr
<br /> cn 95-38
<br /> Hauler Telephone Number IiE s; Address Same as Hauler faf,
<br /> /�/ t. / ALfar I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE �Q� /^�
<br /> t/v�'J''a1( :,r Wfttl1�'l 11'Y$�' LAWS OF THE SIMS OF CALIFORNIA THATTHE �
<br /> .t INFORfMT10N PROVIOEDAHOVEIS TRUE AND CORRECT
<br /> .e o. Number Load Information
<br /> d al 7✓V� L.V V.' �`r:B' .�� tY I)�:I �`I' i..�f)1I1r+/�.tII
<br /> HaUler'rlre-P.rogram'!ID ;/ Ote Suff IX, � iii jr 'ele}Sh'bhe;hC iTiibef
<br /> EIH 0
<br /> .a
<br /> "12 itL hl
<br /> ,, N�i)if 1 t I ' V
<br /> Hauler Name ,�I � !ri).tr.:�tZtf'�)d: •�'�''�'1� C`�
<br /> Telephone.Number IJ Hddrs
<br /> Hauler was tt5uler /narp,5
<br /> RRTAOfFY�HATUypER PN+
<br /> FH$T)EOIFTdYRONF1ATHAJTP�AIUTHE
<br /> dNROGadABgVE7s OF THE ,/y
<br /> TRUfi•AND.,pARECT 6A
<br /> ComprehensiveTrip Log • • Information
<br /> r I
<br /> S
<br /> 5630 0=5 �"®►
<br /> Hauler•Tire Program,ID / site Suffix I F Gi�jtY �elsph;orte Number
<br /> Faeiifty.tit e l.
<br /> Hauler Nance`'"t
<br /> Hauler Tele htine.Number Adardss Samd.as Hauler
<br /> 4 nitle/e
<br /> I CERTIFY THAT UNDER PENALTY OFPERJURY OFTHE
<br /> LAWS OF THE$TATH.OF CALIFORNtA:THAY7HE
<br /> • v
<br /> CIh
<br /> J.
<br /> f � INFO tMitON PR YIOEOABOVE IS TRUE-Aho CORRECt.
<br /> • . :. - {2-M:•......-.. .: ... ..,. >ri - .. .;3[:a.e.'�• .rte"`
<br />
|