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09/29/2015 10:38 Darnels Tire-Santa Fe Springs (FAX)5626981812 P.0021002 <br /> . pNAY ^Q end Rw7nwry <br /> CA Qom rehensn Tr.1' Lo and Roca ' is �� RSO. 2*Setri&WAM116CAVW2-TM <br /> C$I" e E x -A.M P G .E:: 2. .3 . _ <br /> • � �Number <br /> m e en e <br /> n3Zw7M(Ag11NSTRUCTIONS ON BACK OF PART 2 Do NOT TAPE.STAPLE OR:DUPLICATE <br /> BY Np 0 "OA Coropn Mn91r•Ttq L••end 11019101,Ow*1WMW rwwwt ort Ow Infwwo•oo povtded 1n We fan*wR W Gr ewM c1 •nd Vadv a1waL to nsoori ow wM INK w CCR ftedon <br /> LMH at aq),V•rnw ol10 nuW*for dlwAa*wa dOA1 Wbrwl•on,CaR1oa11 M panlaol dw 1L•AIM)of•da Torn N the oddroW w91 Maphom m,.- paMd•d•A Md•(pat•tate* <br /> Hauler Addeees �— '. . . . ' ✓.'. ,� . �-1 <br /> „ . ''' Susl�ies.Naine <br /> -Ih <br /> Cl*State.and Zip ,P <br /> >` < Common . � Ci/ '' lo <br /> . ,. . J <br /> 1 Carrier <br /> ...i.gruy uwrlJwwWa p li.v andw d.4w a N10wa dC•rbrw uW ul rwnniao*prw�a•�uwr r aw wd avno�b ltlaYen,� that 01 dWd awn•wN af: <br /> tM rN11L1 T1•H•M1r R to ae•e Rhe*edo w Gorallen rano.�d mWiwlt in*ApenMtivlw to tE•,•oo Pw dty w PIN-16111"w to am 0,!t7 <br /> LA•10tlan 0•I dp r dllnbl••t Pt•t•e Rttlouow <br /> CoOI••ettalt�3n0 . <br /> - r <br /> Drlvef'e:Name 'rint) . _ d. �Si 'n ure"': Date:. <br /> 11""L+j Comprehensive Trip Log NUmber Load hifoiniation Facility Twe Program ID Site Stiff ix <br /> 4951163 lod -C = F1 <br /> h <br /> J " <br /> veuler Tire Progrem'ID'`/J > Ite$ufftic - `� - �eicillty.Telephone Plumber <br /> a, <br /> ' .D:O -�•0� 0 D•�� <br /> �. Planie/Address <br /> City,State.and Zip <br /> 1 1 Stamp or Label 4K <br /> r Telephone Number. <br /> Address Same as Hauler <br /> Haulere I,. ❑ • <br /> ,,11. i�w It1• :. f 1C/R1IPYTHAT OTHER PENALTYOF PERAMYOF THE <br /> t,-T+�k'1 it. . y�;�' '1 urvaaTla5?M0PCAU/ORNIATMTTW <br /> •c c.• >" :1'•L1 .NM1rO11MNTON PIIOVOW ABOVE N&TME AIA CORMCE <br /> r' Comprehensive Trip Log • • Progi ain ID <br /> _ <br /> . 49 <br /> 63. <br /> �:. , . pi <br /> • <br /> �d" DOE. <br /> Yr-.,;,00,w <br /> Hauler The Program ID '! SRe Suffix ;` <br /> x '.1� v., � '.Faclllty'Y0lephorio:Number <br /> � 7�+ ZEE.R RR d <br /> Riow Y !! f <br /> Hauler Name nT ,:.. �( ' Ipvr^C!QO iiW of I/¢ <br /> PA <br /> "Ha le Telephone Number. _ :;.❑ •Address.Sarn as Hauler <br /> '. :7r•� ••`','1.t� ')tet•. T-, ICS!.TN/tt V4poiPENALTYOPPIRIINlYwrw <br /> '+ - -1• i 1 AA LAWBO� 8fAT111611 UCTHATTit <br /> r�-• .. .•►.. r = `1' iNidwatATioN 'ABOVBATIYIBMIDOORBrCT: <br /> Comprehensivo Trip LogLoad Information • • <br /> gram ID Sit.0 SLIffiX <br /> 1, 01 <br /> 4951163, <br /> Hauler Tire Program ID / '81te Suffix ' ''Fecllit' T®Ie0Fl6ne-Number <br /> Own & L <br /> J: .iati's..'1•' t r,, rhipl Ai; . C, �'� $i(1 �y�7� ' )•� <br /> .+. (� +^ Vali�h�t ' laio , is•,,[ �iil"# M ,tr+� "l r"`-''Jf" <br /> Hauler Dame //e <br /> E Hauler Telephone..Nl mbar w Ifi'difr" s Srnh6;3 'Habil r <br /> d /nnaa <br /> n n '✓ N •i .f-- ,Ir'�:`. ` '{.r,;�1 ""•..' .: t I CF,RiFir rHla'uwOFn PEi}ALTiaF vl±IlJuin OF THE <br /> LAVA OF THE BTATB OF CALIFORNVI THAT TM' <br /> OIPORMATIall PROYmEDA90VENrt AND CORRECT. <br />