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11/21)/2010 18:24 2099571008 17228CARNIC.MERCADO PAGE 02 <br /> ..r� 4197994 <br /> ,Mr--, INSTRUCTIONS O OF PART 2 DO NOTT PE STAPLE OR UPLIC TMEe.s.«w�. ��na14O. <br /> .Nf6 293:e9 ow no Mooiuen erwat.d 4.v+.rangy r a mn.rsn.a l acerMbrr <br /> BY.g..tng aro CA curry 7ta L°0 „yT a. W d1J.fovea N�¢a0lne and M,aauEar DtuTlaed on 1/.0 tom orrvt•p. <br /> 770.1 at we%..Y a r*a—b maga ca deal a dCbl(Ms <br /> Hauler Address <br /> uck Decd!Number Businm Name <br /> 0 0 0 Address <br /> 0 <br /> city, State and Zip <br /> License Pti�tB Nurlber El <br /> ' <br /> 110 n rry CommonU 1-1 Carrier <br /> I ceryly un0er va+etlr d PM WY vyoe.yM a...d mr to WkMA@dM p.. �...m eve awa o,.a In.churn.I OM WOM mat mhft-M-d tris i�te,m tun may�earM h.u.panefon. .w�FOTT) <br /> I Qw TNa 11 pw�y*1 P M -dwMffwab Ptda .2CAM dl60D a.,d mq(avert MdA p..Oft M b;M000 Pr day,P-gdW-w d�•a� tDp$5.000 Var-*0101'P°f d"°0 <br /> G Drlvees Signature <br /> Driver's Name tint - <br /> Load Information <br /> Comprehonsive Trip Locl I i i inber <br /> i <br /> .� 4197994 Puck Up Delivery <br /> a <br /> � n n Facility Telephone Number <br /> 0 <br /> � Hauler TIQe Program ID 1 I� uflix DATE. 00:./ n <br /> � � 0 <br /> U) <br /> wlwle!T"Cunt wMeht m Lbs. Doo-0000000 <br /> eepp 1 w:,r:e�st�f�U�+B"1e3s.fi <br /> g O Volu"Come Yds- 'W61ght in Tons 11�A tY� t/:eWfic3rc-�y <br /> CiTy.,Stat-1110 Zip <br /> Waaler Name <br /> ^'LRT—,-.p tar <br /> v El Address Same as Mauler <br /> r <br /> 'IOU 11 <br /> Hauler Telephone Numb !com"TMT comet P®dt.7T Of renal+(OF,TM <br /> b 0w for Llw$OF nE STATE Of CAUPOWMA MST Til <br /> %JM AMM OM <br /> fill Mill <br /> a <br /> 4197994 Pick Up Delivery <br /> ' 0 110 0 110 <br /> '�J <br /> -- LFacility Telephone Number <br /> Hauler The Program ID 1� Suffix DATE <br /> -0000000 <br /> W [] whole Thw CMnt W fthe In lbs. <br /> LL 000 <br /> Volum*CuMe Yds.Q weigla in Toms nbal.zel .t �srsc s <br /> e«;ilk'"�`tkl + sr!t Gly <br /> oHauler Flame <br /> Stamp c>r k,.3.k5F! OK <br /> C� I <br /> J <br /> ! i a '0000000 0 Address Sarum as hauler <br /> HauierTelephone Numb ICBrrit'TMAtUNMMMALTYOFPIKINJO FTlE <br /> Lm"0•TM!STATE OF cALWOMA TMT TE' <br /> • • . . .. <br /> • <br /> b. <br /> 4197994 <br /> Program 10 1i11 uflgx F Facility,Telephone Number <br /> Hauler Tire Prog ill , <br /> ;> B-R <br /> I I .( <br /> G <br /> er <br /> A- <br /> uuII pp { <br /> Hak '� <br /> �rPlep .on NuM bSI �Yi _ Tt, l XinrY TIAL UMEn PEMALTT OF PJM*MtT os.THE <br /> LOW OF TMOrATEOFCALIORMTIATTR <br /> f - <br />