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I <br /> I l t* <br /> F T. G. CONSTRUCTION MATERIALS, INC. � F.T. G. CONSTRUCTION MATERIALS, INC. <br /> 51 W HWY 12 <br /> 611'j2 W HWY 12 <br /> LODI,CA 95242 LORI,CA 95242 <br /> (209)334-4038 (209)334-4038 <br /> I <br /> DUMP TICKET No. 24089 DUMP TICKET NO. 24090 <br /> 11 <br /> DATE= 7' ley — *3 TIME �� OAT !t-1 HTIME <br /> ORIGIN n I ORIGIN , <br /> DESTINATION DESTINATION <br /> CONTRACTOR'S 9v��� CONTRACTOR'S <br /> NAME/BILL TO NAME/BILL TO r <br /> PHONENUMBER ) PHONE NUMBER ) <br /> TRUCK TYPE MATERIAL TYPE j TRUCK TYPE MATERIAL TYPPJE <br /> Minimum ❑ <br /> Clean Asphalt ❑ I Minimum ElClean Asphalt 13 <br /> 2 Axle ❑ Clean Concrete Clean Concrete <br /> 2 AAxle <br /> ❑ <br /> Clean Fill Dirt ❑ Clean Fill Dirt 113 Axle 133 Axle ❑ <br /> �.� Concrete&Asphalt(Mixed OR I Concrete&Asphalt(Mixed <br /> 5 Axle Concrete&Dirt OR Asphalt&Dirt) ❑ 5 Axle Concrete&Dirt OR Asphalt&Dirt) CI <br /> Concrete&Wire or Rebar(rebar& I Concrete&Wire or Rebar(rebar& <br /> Wire not to exceed 6'beyond concrete) ❑ I TRUCK NO Wire not to excee <br /> TRUCK NO d 6'beyond concrete) ❑ <br /> 'Contaminated Load(Material l � 'Contaminated Load(Material <br /> wlplastic,wood,paper,debris pipe,etc) ❑ 1 I wlplastic,wood,paper,debris pipe,etc) Cl <br /> LICENSE NO 'Oversized Loads(over 24"x 24"x 8') 13I i LICENSENO 'Oversized Loads(over 24'x 24"x 8'} ❑ <br /> 'Excessive Rebar *Excessive <br /> n 8'of concrete) ❑ <br /> (Rebar beyond 6'of concrete) ❑ ` ( Yo <br /> OTHER ❑ ; I OTHER ❑ <br /> t <br /> "Loads considered"undesirable",maximum rates will be charged *Loads considered 'undesirable maximum rates will be Charged <br /> The following signature Is verification that the material which has been i The following signature is verification that the material which has been <br /> dumped is not hazardous and that the"matenal type box that is marked j dumped is not hazardous and that the"matenal type box"that is marked <br /> is correct TOTAL DUE i i Is correct ��A i <br /> y119 <br /> DRIVERS SIGNATURE DRIVE �SIGIATL�:� <br /> OFFICE COPY OFFICE COPY <br />