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an ing and R*co�ory CA Comprehensive Trip Log and Receipts OaPCox1250urccramentl.CAR512-126 10002 P.O.Box 1269,Sacrnmonto,CA 95812-1258 Com prehensive Trip Number CflmydB IEIXIAIMI P1 L I E 1 2 3 QMX)aaavrTnaINSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE,OR DUPLICATE Y By sign- mnNns d"CA Coprahave Trip Loy and RaoalpC the slyrisi rows!that the lnlo—.Uon p—dsd on this form.ria be—W—d.—Nd—tial, rwwen ,,roPrl. y"tra t.M--d—with Tats.is CCR,aac$n 1 T W t a1•ag.,if a ragnasl is roaaa for diaclo—of this Wor "Or%CalRacycia w1w conlaU the siyner(s1 d this Iorm•t the adore"and talaPh—number pro0dad an this I.—rw-ipt. Vehicle Inform tion ^n� Hauler Address Truck Decal Number ...� ❑ ❑ ❑ ❑ Business Name Address City, State and Zip ERR] icense Plate Number State 110 ® M 11Carrieron LC-- - �Q J I aar4fy untlar pM,aay d prplry,a^clsr L.-of the SLIe d tta 7Ve HWa Rpia✓atgn W n P W�c ReawceCsauhq1 t�ha' mn1 mpy orev+nodW LIlclMovl apnerw1wWes roup ctao rfK7Y5,0Na:1on, Dmar wM-utta4/e".16n a1 dna/xrnnon+ay aIn vde Or ever.;*psna9roLP to 55.000 pa coo. 2y2ewe 4wastpgsnnpwrnd,amy ss pL boer ddoInn P-aot6creRrnswsaawl ocfe a ' Driver's Na�rint Driver's$ign "ature bate Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix — 4858914 -- a - Pick Up - '/ .Delivery ❑ '� L — '�) / a Hauler Tire Program ID / Site Suffix DATE � / / / I' Facility Telephone Number- U U Whole Tire Count ❑ Welght in Lbs. Facility Business Volume Cubic Yds. ❑ Welght In Tons Name/Address o Hauler Name City,State and Zip i `� U t 1 11 �_ i Stamp or Label OK 1 ■ 1 '�Address Same as Hauler nlfral Hauler Te p ne u beer ///��x (NIA for ICER Y THAT UNDER PENALTY OF PERJURY OF THE /I' �' \ Wh01•Ti10•) LAIW OF THE$TATE Of CALIFORNIA THAT THE f J IfIfORYAf10N PRONOEO A80VE 18 TRUE AND CDRRECC Comprehensive •g Number Load Information Facility Tire w • 11) Site Suffix 4858914 8 Pick Up Delivery ❑ —❑ Facility Telephone Number cc m Hauler Tire Program ID / Site Suffix DATE ❑❑ / ❑❑ / ❑❑ / w Whole The CountWeight in Lba. ca� 0(,4 Facility Business I Volume Cubic Yds. Weight in Tons Name/Address o Hauler Name City,State and Zip U � Stamp or Label OK H le�( o tuber W I ■ ❑ Address Same as Hauler fnf!!nJ (NIA for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE t Who[•Tiros) LAOF THE STATE OF CALIFORNIA THAT THE W. V NFORMATION PROVIDED ABOVE 10 TRUE AND CORRECT. ComprehensiveNEW • Log Number Load Information Facility Tire Prograrn .EL4858914 -- /4. �' Pick Up , Delivery ❑ ❑ ' /� l' —�F Hauler Tire Program ID / Site Suffix DATE / / I. Facility Telephone Number cc o Qv a Whole Tire Count Weight in Lba, ❑❑ ❑ ❑ ❑ o ! I�i Na /Adsill., ss Volume Cubic Yds. Weight In Tons Na 1Address`, l oHauler Name Cl� ,�ty �i (,lr& )Y Address Same as Hauler uler I on Nu ■ ❑ Indla er I I I 'w1,\,1[`h\' (NIA for I CERTIFY THAT UNDER PENALTY OF PERJURY Or THE Whole Time) LAWS OF THE STATE OF CALDORNIA THAT THE WFORMAMN PROVIDED ABOVE IJ TRUE AND CORRECT.