|
02. CA Comprehensives Trip Log and Reoe`Ipt �000z po BoX, 9 s��iame;tp�; aasa;z , R . ..
<br /> Com rehensive fir( Number
<br /> • -��fReC C18.�� X' A M-P t i~ -.� 1 2 3 _ .. ... .>_, s, ��B
<br /> Y S
<br /> SHH;o1C+rN _ E.
<br /> ( /Y t { l r y ; -1(V r.
<br /> eaurr.'i9w'oaojlNMUCTIONS-ON{SACK OF PART 2 DO NOT?APE;STARL�:'OR CIUPLICAT
<br /> .�Iysipnlntl.thiscACompnhensly+4lPLopena'R+eelpt,0us12nei(e)requset.thatthel formal(on.pmYldidonlhliform WUlhocanddire6coh6d a I,propyl 1 ry nd trd l.1 aceor8•dee wllh TWe;1i 0CR,6eollgn .
<br /> I
<br /> 17D41 at soq�;li.e roquoat la made for dl+etofure of lhls 4iormattor,CalRecycl+Wlllcgntact,lNa dOniKsloflhl+iotm•t itis eddrcn and tdophonenumharpmvldad on thl+torm orncetptl
<br /> TPuCkDecal Number
<br /> ' Hauler.Address,
<br /> n Business Name Eak�:136t i Ti r e 'COMParIV -
<br /> �at 1{® — Adyress ;
<br /> Git State and Zip. 0-20.OXHunting t6n r-
<br /> Lidb#Sse.PJaiQ Nufnbar Si�ate �
<br /> ERE'
<br /> Car ier�n i
<br /> 1� 1Y� � ; CA 94533
<br /> !codify under pmoF-y of per�uy under U*levo of the State ei C�fam i IMt Ih+ tortliatlun proNded shove la flus uW conxl..ln addlUort,:i sm'awen Ihst f>tallkaUon of lhla Irif sUon may mull In auspenalon;revocation;cr denlaf of renewal of'
<br /> the Wes(6.Tke Hpoler Regls6allm pursuan bTo Reec m+s:t:adesac6on 1 W sed mry ieiuR.M'cM1rN peneitwi Io$-26A110 psi dey,par ai admNlcuallvs penal es up to S6,OD0 per vloleUon dey v de+c hed.In PUblie Resource
<br /> •Cbde s•0Uon A21162 '
<br /> Driver's Name print] bnver's Signaf Data
<br /> t. Y( nsizie Trip Log •, • • •r R Site Suffix.:
<br /> • •
<br /> � t!�`T,�,( �li I{�P'{"s�'�ri4 it s}•1::1 Fri#1
<br /> 'lM1 —_ lM1Z i.L] 71c7`U I
<br /> '5757 8;'6'9'
<br /> '�-
<br /> 1 Si
<br /> 't-lauier'rire Pro ramWID' be•Sufflx'
<br /> ' IN.
<br /> 7� )L;:;• hiol �Tire Go �1 T.
<br /> 2
<br /> llil � 't
<br /> x ca• � s�i+ < Facility eiisiness.
<br /> (' Q�d ( l;t'nT.0 :NAriie/AddhMSt--.Bqy Tire Como
<br /> r0.
<br /> " f' City,'Siate aricJi V f1U�
<br /> o� Hauler N Mme - k` J
<br /> k `
<br /> Cid 9583$.
<br /> p r onto,
<br /> St .
<br /> am or Lei�I� '�
<br /> L
<br /> Hauler Telephone Number —Address Same as Hauler mJrrei• _
<br /> LAWS IFYT E STADERPENL]FbR F PERJURY OFTHE
<br /> yVGt `GJ.+ 'G,/y -•GY rr t `tl`K '
<br /> Jinja Tr a tAVV9 OF THE STATE OF CAt1FORNIA THAT THE
<br /> - "v'A•;, ✓ f,J... '-'_.�,u....n. ✓i tr,..l!Y'f:z.,d_>::e.St_.T, n\,4,r-?✓.b.f.ve .INFORMATION PROVIDED AnOVE I6 TRU E'AND CORRECT
<br /> ID.',z Site Suffix"
<br /> Rf
<br /> 5...7.5.7:8.6'9 - YI u' ., ..ia�>I 0 0 0:0: .
<br /> 0r .� � FaahtyTelephone Nu�ler:
<br /> a. Hai#fer Tfre-Program iD ! S' Suffix 'tl (
<br /> xb ;r 4llw
<br /> � Facfhty.E3uslness`.
<br /> �•' :: k'yP>':: t , ' �;�'l aMN
<br /> w � � !Tott r'.Npnte/Address
<br /> �.• d .,I r < i sl s � t +z' C)ty,State and Zip
<br /> �y7�Ar Hauler Narna - ��� s� t ��w t� �• . ... -: -
<br /> f EllorLab .OK
<br /> 1. ■ s Addres Same as Hauler JnlNela
<br /> ;. Hauler T ephone Number .' z�
<br /> r'lk rl w .{NIl}fof .ri I regTIFY,THAT UN PENALTY BP PFRIII•RY OF THE
<br /> .�� 1.4 k ,, yyjip7p�'�'r�•1 t LAW&pFTHE ST E OF CAIIFbRNiA TNAT THE .
<br /> 7NFURMATIDNP OVIDEDABUVEISTRUEANDCORRECT..
<br /> ib l� yc
<br /> a
<br /> �x v tK rye q�.'�€4( r� �:", .3 a & f< >, �>�• ii- N
<br /> .,�- ,.>>?r�•. -M3dc- -S'` �S�,T, " Y%'�=.�u�7. nw.,�i:�• �' Y r
<br /> !gr y •4"3C---"V'-Y
<br /> Rr,4 ', '3
<br /> $f � ry> f�re � `'SE� '� t i alI i •ZL� E , Her' • ! i
<br /> s •R ;x. t ��:.+ fit* •;� u •'t �!� ,i r. "'
<br /> fiPt�'o+l.lj
<br /> P.
<br /> X r' _,•F• ,." �` c=ar I , 1 � : s? . f T '.9r,>� � �` FL I ;"
<br /> i ��Ie�r [R��`�'ly�§ •�`-# f�'l,, �ZF i t f^ .,t„ >r� S^ ,}.✓ �� �t, - st,;
<br /> q to '.i .�i d�.: � ( $'r u�) r y{ -✓Cn��'
<br /> 104 F S
<br /> "r[,' w rrlk` c.'.u.:�,Y �:;Kd ,.�- f�'C•�- .iv T�S,eSR_�x -, ~Y � _ T,.IN.YP.Li Td�.�.E�A.� �qii��.T8� ,W_ _11.2
<br /> �
<br />
|