Laserfiche WebLink
uepl.ur ne...rue.nouyveny----y <br /> CA Comprehensive Trip Log and Receipts 10002 .0.Box 1269,Sacramento,CA 95812-1259 <br /> _ <br /> C8lRecycleEXAMPLE1 Comprehensive Tri Number <br /> 2 3 <br /> araf•ayc,",'J <br /> calKyrJ.mJ,7mliraylNSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE STAPLE OR DUPLICATE 4796350 <br /> By signing eda CA Compr•henstva Trip Log and R.cdpt,the.19—(a)r.q...I that the Inform 0—provM.d on W.form vA0 be eoneldered eonlhtantlel,proprl.lary and Irad.secret.In accordant•with Tilt.,14 CCR,Srcllon I <br /> 17041 al a.q..II•-W-Irt I.made for dfa.b.ure of Ihla Inlormallon,Cdq•.y.ls vA11.enlace the alpn•ryq of INs farm at the address and telephone number proNd•d an IN.form.r nc.lpl. <br /> Vehicle Information <br /> Keiulei Address <br /> Truck Decal Number f1r �,� - t ,/� ;•G,r��.� _ �%'t'jl`()f�,ti 7 <br /> L.it.tsiness Name <br /> Address <br /> 111 Unel l (:ity,State and Zip <br /> License Plate Number State <br /> Common � <br /> <: JL]I:, .arrier �f�- r <br /> I certity under p.nefy d perFeaws d y under the lthe Stale o1 CaIHor is that the IntormaUon provided at—III true and torted.In addition,l am aware that IaNRk d this Information may reautl In su.parlsloo,ravocaUm.or denial of r.—.I o1 <br /> the Wazle Ton Hauler Reghlrallon pursuant to Public Resource.Cods stolon 429W and may result In chit panaNl"up to$25,000 par day,per violation or 11ys Oenalllas Jp 10$5.000 pr NWoUon par day es ds..nb•d in Public Resect.. k <br /> Code seta..12962 <br /> Driver's Name print Driver's Si nature """j4Date <br /> Comprehensive . . Number Load Information Facility Tire Program <br /> r1 <br /> -4-796350 -- C 5Pick Up 11 Delivery&L <br /> cc DATE ,/ as ;' Facility Telephone Number <br /> (D Hauler Tire Program ID / Site Suffix <br /> ( H © aoa <br /> c w a Whole Tire Count ❑WeightIn Lbs <br /> ? i VOlume Cubic Yds. Weight In Tons r' t <br /> E (-tauter Nanu> 1 <br /> Q <br /> tjanl(;r TL31epho(to NIIttM(JO( ■ (�/ ' Addrle vs Samo as(-hull,!' <br /> (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE <br /> J��;; y/ J j '•� <br /> Whole TIfYs) LAWS OF THE STATE OF CALIFORNIA THAT THE �t l/I�,.. <br /> rr—ncn A—urr 1.TRIM A rIn r:ORRECT , <br /> • a e Log a •.• • • •eram <br /> D Site Suffix <br /> 4796307 -- A � Pick Up Delivery r o r-��a < � a <br /> MDATE Facility Telephone Number <br /> Hauler Tire Program ID / Site Suffix <br /> N oaa� oaaaaoo <br /> ow. a Whole Tire Count � Weight In Lbs. _ <br /> f ( � �% 4 Volume Cubic Yds. El Weight in Tans il'Ptl li• !� / <br /> o Hauler Naar; <br /> U a h <br /> Hauler Tolophonc Maubcr [DUDE. � {� HcltfreJ,l tialtm8 as Hbulet' pals y <br /> _ (N/A for I CERTIFY THAT UNDER PENALTY OF PERJURY OF THE r� <br /> STATE <br /> Whole Tires) LAWS OF THE OF CALIFORNIA THAT THE P{ <br /> I INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> Comprehensive Trip Log Number Load information Facility Tire Program1 <br /> Site Suffix <br /> El <br /> Pick .�-.. <br /> 4796301 -- B Up Delivery © �� .`� �_ a E P ' E <br /> - <br /> L l <br /> 41 Hauler Tire Program ID / Site Suffix J Facility Telephone Number <br /> DATE <br /> aoa�� 0000aaa <br /> Whole Tire Count � Weight in Lbs. <br /> oVolume Cubic Yds. Weight in Tons f ;: <br /> Eto <br /> .J <br /> t r r <br /> U <br /> Hauler Tr,le(il lcrnLS hlunll c.r DUEH'Ho II l4ddress Same a5 lial Ilex 711(t(ars <br /> �1 / / r •�� (� ) (N/A for ICERTIFYTHAT UNDER PENALTY OF PERJURYOF THE <br /> I✓' r'^C f I /f� � �� �.,; � Whole Tires) AWS OF THE STATE OF CALIFORNIA THAT THE p `/ <br />