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CA Comprehensive Trip Log and Receipts 1D002 P.O. airy ,3a•�„�to,GA�;2_M <br /> w E X A M P L E 1 2 3 Comprehensive Trip Number <br /> o+Lrfeftl�lnno INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR ICATEL . 5 3.0 7 8 2 o <br /> 1�70etp�tq 0113arn <br /> CA cPrehenelre Loo aM Receipt,the riN rea+sq that e..bft—AHoO We <br /> Provd on we farts W"be ooaNdmW confidenD•6 PMPdetarY end trade eacrrL to•corn'dance with TING,14 OCR,section <br /> e0o,O•1006-11.meds for dLxhaurs of N.Wan min,G Flocr le.0 oonb-A d»elpnwfal a!drta fertn et the M Wr end tWDhorre rem bm provided on Mh Iorm a ree ipL <br /> Vehicle InfortnaUon <br /> Truck Decal Number Hauler Address <br /> ® © � ® Business Name µ(,ms Cony <br /> Address , 135 S. Union Street <br /> City,State and Zi�ckton,CA 95205 <br /> License Plate.Number State �4 <br /> on L <br /> Carrier , 1614 <br /> 0 <br /> I vrtM/under P—JAY of Poriury under Ilw h­of Iha State d cAfomia that the Infra, don provided above h Inn and cci ea In&,Wion,I—ewan that faW1r jlon&V"WvTNLon m Y,talc In suaptroWrl rnnxaLon,tY daNd o}rvwwy W <br /> tCad•bvcWn 429Q In Wcvd Tim K=Aw Moiavellon pcaau•rK to Ptb.'!e Raaotapm CA170 seafon 42D90 Ond mry rpwlt h Gvi penatlMe t:P fo{?3,000 Der aey,per via:et,On m adrn W aSPllve Pon,8¢a uP 1 <br /> 0 55.000 Par vbaaion Par day as deaatsed M RCt:e Roso.acaa <br /> V's �(�c' �C�UtIGc-ta /(J-^G'l��Z�ll� <br /> Drlvees Name Driver's 81pnaUjre Date <br /> Comprehensive . Log NUmber Load Information <br /> Facility Tire Program ID Sitf,, Suffix <br /> -5307820 --. C Pick Up- Delivery <br /> Hauler Tire Program ID / Site Suffix Facility.Telephone Number <br /> - 9 DATE p <br /> � w � <br /> Whole Tire count �Weight In Lbs. <br /> g 177'f 9 3-01 <br /> Q ❑Volume Cubic Yds. ❑Weight In.Tons �/f�T' f 1 ''yfl//I` (J <br /> Haul(2(39)1'98(-1614 ^ `pCy1�`�//1�� <br /> U � <br /> Stamp or Label OK <br /> Hauler Telephone Number WRwE0 ❑ Address Same as Hauler <br /> (N/A for I CERTIFY THAT UNDO?PENALTY oP PERJURY OF THC <br /> Whole Th,,Q LAM OF THE STATE OF CAL{FpiWU THAT THfl <br /> "— _. INFOIgLLTpN PfipYG)m Aa10yfL le TlttlLt <br /> Comprehensive <br /> MSite SLlffiX <br /> 5307820 -- B Pickup Delivery <br /> Q Hauler Tire Program ID / Site Suffix <br /> Cr Facility Telephone Number <br /> DATE <br /> � u+ ® Whole Tire count ❑ Weight in tbs. <br /> r� <br /> � I <br /> 19 774 � <br /> m 1 ® ❑Volume Cubic Yds.• Wei ht in Tone <br /> E -Hauler Na <br /> (209) 986-1614 ^ <br /> � <br /> 3 Pq OE ca <br /> Hauler Telephone Number Stamp or.Label OK <br /> ■ Address Same as Hauler. <br /> (N/A for I CERTIFY THAT UNOER PEMALTY--i— —TT I Mw <br /> Wholo Thouu} LAWD OF THE STATE OA CALFQRNUI THAT 4; <br /> INFOR1aAT10N PROYpED ABOVE fs TRY2 AND COfLIlCL <br /> Comprehensive Log Number Load 111formation ' • <br /> gram ID Site SUffiX <br /> 530782o. - -- A Pick-Up' Delivery , <br /> Hauler Tire Program ID / Sfte Suffix} DATE a' �y i / Facility Telephone Number <br /> /� <br /> ^1 W <br /> 2 CL 1-4Whole Tire Count Weight in Lbs. E0/ —® ®® <br /> ❑ g s. <br /> m ® ❑Volume Cubic Yds. ❑ Weight in Tons• <br /> N Nauler��9�1614 . . . �• "�f:%`�j'l�.� G�/_ �S%-�s�� <br /> a t l <br /> Q, - E .^� 9 Stamp or Label OK ' <br /> Hauler Telephone Number ` i 0 Address Same as Hauler <br /> (WA for I cExnFY THAT wDm PENALTY OF Ppt_, <br /> Wholo Tiros) LAWS Cr'THE STATE OF CAUFORMA THAT THE <br /> INFORMATION PROYIOM ADWE Q TRUE AND coRREc'T. <br />