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Jul 18 13 12: 03p P. 5 <br /> Toll Free 1-866.896-0600 / www.ciwmb.ca.gov/Tires/ , <br /> :;jq CA Comprehensive Trip Log and Receipts P.O. <br /> II3g lnbyyra lRemm r,CA96e12-12W <br /> _ 7 n W �002 O.�975a,eacram¢nto,CA 9ce��_�Zsy <br /> L�^x`,F► ra► wJ` a ; i , 2 : ;r � , Comprehensive Trip Number <br /> c "n INSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE, STAPLE OR DUPLICATE 3860950 <br /> Bar alanlnp tltk:G Conlprot onehe TO Log and tt-AIF%the slpner(e)r%queat that th•Information parched w Min(oma will be r Idarad confldontial,prop•latarr and aedo eedrel.M s000rdeaca wM.TN*.74 CCK E$dUon <br /> 47WI of sea-n a raQuoel Ia mad•fpf dlacbaura of the rnllnn•Don,We Crwwms vw r c- inct We sWnr(a)of Blls foam at atla adar-a and Ialesn one nwaboc Prorldaa os M%roan or rsoalpt <br /> WWI <br /> Truck Decal Number Hauler Address <br /> Business Name <br /> Address <br /> N © -- o EI a a P City, State and Zip s �? <br /> Llcersa Plate Number Stare <br /> Common I��C,G� C� <br /> I cartey Jnd..pe'•7b o)pogwY und¢r(r,o IaWa cl Ilia Bttln orC:ofbn:¢reset aha InPorm¢lion D'OV'LDd¢Eovo to trua and concd.In oddabn,I om oworo Ih:(lalelfamUn o/(n�wagnoGo,t moy raau'1�+1•d Panton,nuocnoon,cr d¢Nat or rona.elof(n <br /> 'M,elo T,a neubr ttavbrmlvn ovr!aient b Pubis Rewrap God••VC6Vr.•29CQ.10++.Y rata.'11r rr•+pe1•IUoa up 10 4 25,000 Pard pa a iw o•ad'iPioROOvo pa."It,o u to%5.D00 M Adel;-pw day n daeer;brd i�p <br /> ubk Ree— <br /> code vrsm 4Ztr.2 <br /> Driver's Name ( rint) Driveev Sig ature Date <br /> CoMprehensive Trip Log Number . . . <br /> CL <br /> 3860950 Fick Up Delivery a Ll [1—E 0 <br /> Hauler Tire Program ID / Site Suf iat n n Facility Telephone Number <br /> DATE a /Count <br /> m W Whole Tire Co weight in Lbs. o o a a o a a o 0 <br /> � 8 <br /> El Volume Cubic Yds.D Weight in Tons h <br /> ,$ 1 aider Nome rig`/r yC9tiy 2ci�i.'i.}� <br /> U :'Six(Y1!): 2..+14`52''t <br /> hauler Telephone Number � UDW Address Same as Haiu!er s <br /> (H!A for (CS:7TIYY THAT Uwiffl FENALTY OF PEA.lIIRY OF TRE <br /> 1Vitala TTros) lewd OF TME STATE OF CAl.DRItf4 TRAY Tl� <br /> INFORNATM PRUM D ABOVE O TRUE AND CORRECT. <br /> I k <br /> _ _ _ � - • a • • Program1 Site suffii <br /> .re <br /> 3 860950 �_ B Pick Up ®«y®� <br /> Hauler Tire Progtrim ID I site st,ff-r� DATA Facility Telephone Number <br /> u © a ©-o �ooa ®� <br /> M a [] Whole Tire Count Weight in Lbs. ` <br /> i Z �( QI (� � , v -�c;i i;F t3xts; rFC� 01r"� I <br /> a`t Plume Cubic Ydi.Q W0)<Aht In Tons <br /> Yvl G <br /> E C�tT�r :..sin F;, ;�-., Q C�tj�� <br /> I-latjier Name -. �< <br /> PHiwk?r Telephone Wmbsr EDEEE-Fo E Adair®ss Same as Hnuier <br /> ' K <br /> SN/^for )EEMIFY THAT UMBER Pf kAiLrf OPI PIRAIkY OFTHE <br /> (_,;t 0�}O M/Itp)B nma) LAWB OF THE STATE DF CALtFCRJI(<TWAT THE <br /> nlFOR-ATT011 PROV10 ED ABOVE W TRUE ACIDCoiv!prGORRE{T. <br /> - dinsive Trip - Load <br /> - <br /> Hauler Tire Program ID / SiteSuffix Facility Telephone Number <br /> � ':a,. ��i' .. � ,V, `2�k�'?7,T:• �.,�,7CtLJ 1•�i\>t,N aw <br /> �Lj', of <br /> _O :�'":'a. <,l;Tz ,�s'ti rf' °�`':d:�ir4.`'4' r.'.6 J41L'.:�..,•y, - <br /> a?� :�. . '�.li .:�:..._.. .�8 i!•. ,. .. ;.': �,- 1 <br /> `.:�. - `"°.':'�:)S TC:T.'• di'fili\T:T't':;;:r?+(M:Y,':':.'+cl''.:0.!ttt;,"F:+!:�;Yi1CiT�v'± I D6RTIrY TVAT ) �8'ei0f <br /> VlIDFR PENALTY Or T'Q3JURY OF THE <br /> Received Tlme Jul, 18. 2013 10: 53AM No, 0731 <br />