Laserfiche WebLink
D"L of Resounds RscycOny end R•cowry <br /> CA Comprehensive•Trip Log and Receipts : . 10002 P.O.eali T2712DC • . <br /> �r E: X::A1M P L E 1 2 3 Cam rehensive Tri Number <br /> ftlftd <br /> :q'INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE;STAPLE OR DUPLICATE 4855-5 <br /> By 419 Nb CA Crnpr•hen•W ft Lep and R••elpt,the egn•rlel m*"N•1 me Momwdon provided on d"form wtE be conaldu•d owft ndel,proprietary end bfd•••a•1.'In•aaord•nw with TNe.14 CCR:e•o0w . <br /> .. 17041 N M0.N•r•Vt+MI w nude for dleeb•um al We WormaWn,CWR*cnW will contact the LWWIA)of We torn a1 Nue address and t•lephen•number-provided on We forma nodpL <br /> Vehicle int on <br /> Hauler Address v 0gVW <br /> Truck Decal Number <br /> Business NameAdd <br /> City,State and Zip 0 <br /> License Plate Number State <br /> O }� Common I Jah-'�/l \" lJ1 �' v /• <br /> El Carrier. �-- � • <br /> ..., I c•nr7 under peruay W trdr me t■w a the .d milt the information padded aw"is true and---I.In add4lon:I D6 'ol pre•WWW»on a.y t•aA�n w+peinton,mxMbn,r danW a rw wal of <br /> ttr Wart•Tri wulr pvwam to .cubo 42800 end moy rewtt h olvN p•rghle•uv b i x6,000 per per p��•p to$6.000 pr Notation dry n n ft lc Rr unca <br /> • Code eealon 42M11 al A <br /> OO <br /> Driver's Na6e rant Driver's Si nature•, Lid <br /> .mprehensive Trip Log Number Load Information Facility Tire Program <br /> _rX4 85 55-4 7 C Pick Up Delivery' L7-. Facility Telephone Number., ' <br /> Hauler Tire Program ID /• Site Suffix DATE E® / <br /> w ®Whole Tire Count �'Welght to Lbs <br /> a� - UM <br /> Facility Business <br /> Volume Cubic Yds. Weight in Tons Name/Address <br /> m <br /> E HaHer Name City,.State and'Zp.. <br /> O <br /> Sta p or Label OK '• <br /> i Address Sam <br /> e Telephone Number e as Hauler•' <br /> r•>rra • <br /> {1 (WA for 'I C THAT UNDER PQNALTY of PERJURY OF THE {� <br /> Y - 1 Whol6TImal LAWS OF THE STATE CP CALIFORN►A THAT THE •., ._�:.I—_ ,_• <br /> t:: 111 <br /> INFORMATION PROMeD ASM 13 TRUE AND CORRECT.:' I <br /> r h <br /> - p • • MIX MR <br /> p • - •. • • •• <br /> 4855547 B UPick Up Delivery <br /> Hauler <br /> Program ID / Site Suffix Facility Telephone Number - <br /> � DATE Ea / aa•� oo <br /> oao-aoaao.aa <br /> - •� i Q/� r� a ®.Whole Tire Count E] Weight In Lbs.' <br /> Q g Fac ity sin f 1- <br /> Volume Cubic Yds. Wel ht in Tons Na tires 1`�'' ��. . . �,•..,.- <br /> o .Hauler Na a .City, too ary�,i::zips. <br /> m 50'6' �'��1�..• <br /> Sia <br /> H ep N ��ggyyr ■ Q Rutiress� rPt��3.Hauter,/__ , <br /> 't� \, _ (Nh (or - I AWB OY THAT TATEUNDERO PENALTYOF PERnOn OP iitE X.ll��•/" � vn WhoIO T'frOB) IAYM Of THE STATE OF CAUFORNU TIATrTNfi. •..� <br /> WFOR*8M PROVIDED ABOVE IS TRUE AND CORRECT: <br /> Comprehensive Trip Log Number Load Information Facility Tire Program ID Site Suffix <br /> m, <br /> 4 8 5 5`5 4 7 -_ A Pidk'•Up _, Delivery. �. 7DIN. <br /> a Hauler Tire Program ID / Site Suffix- r Facility.,Telephone Number .: <br /> till, I- <br /> 1n DATE ©© / <br /> : : RE <br /> ®-0000:o;o <br /> WholwTire Count 0•Weight in Lbs: <br /> �.v •_ 16 1 <br /> Q Volume Cubic Yds. Weight in Tons Ni e , <br /> p ler Namff � '�.�. .a, i„`4�,r1�l:J <br /> J � 1� .� <br /> of ' Nu tact ■ <br /> n. Lr\j <br /> YYh010 Tiro•) 7tddres§Same:�'s Ha{e , <br /> •I CERTIFY THAT UNDER PENALTY�PERJURY OF THE <br /> (WA:for <br /> ti' •. ��(\,yy\' ..LAWS OF THE STATE OF CALIFORNIA THAT TME V <br /> .INFORMATION PROVIDED ABOVE a TRITE AND CORRE' ""••' 1 <br />