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TI <br /> (D <br /> za' <br /> ' N <br /> < N <br /> CD <br /> N <br /> —A W <br /> E <br /> T <br /> 7 <br /> ProgramComprehensive Trip Log Number Lood Information Faciiity Tire Cn <br /> o <br /> 0 <br /> r 49 6 -- 8 r� f Pick Up Delivery �© © a a E—E w Facility Telephone Number I m <br /> a Hauler Tire Program ID / Site Suffix f f , � / <br /> DATE `�' � <br /> a Whole Tire Count E] Weight in Lbs. o, <br /> aao ® <br /> d (7I Volume Cubic Yds. Weight in Tons ! <br /> o (yrulc� P:+. :sae c <br /> Ch <br /> r�C T'C �� a a FS2g0 <br /> c:7,sH 1143- Tz4z�,7ho:m <br /> (N/A}Dr I CERTIFY THAT UNDER PENALTY OF PERU.,OF THE <br /> WholDTiree) LAWS UF[HE VATEOFCALIFORNIA THAT THE <br /> INFORMATION PROVIDED ABOVE IS TRUE ANO CORRECT, <br /> Light Truck Tires $ IP <br /> Truck Tires $ $ <br /> Misc.Tires $ $ <br /> $ Payment Information <br /> Wheels $ Cash $ <br /> Trailer Placement $ Check $ <br /> Trailer Switch $ Charge $ <br /> Trailer.Removal <br /> Total Received $ <br /> otal Due <br /> Customer /. <br /> Driver ;r' . ,� <br /> Signature: , „j <br /> Signature: - i <br />