Laserfiche WebLink
i t <br /> r ' ;.Dept,of Resource e'Reoliollnp end Re90Y8 <br /> CA.Comprehensive Trip Log and Receipts �000z oiBox1269;8eor9rnenio,0A8G812 12 8 <br /> X A M P (. E 1 '2 3 e Com rehensive Tri Numb r <br /> Y y, r xx Y <br /> crdcs,+•:wrriro)INSTRUCTIONS-ON BACK•.QF-PAI:iT'z b.O NOTT'APE.-STAPLS OA DWPLICATE �.� ..W,: a <br /> Dyetppning lhll CA Oompreh•e•Ivd)}Ip Log and Rocalpt,the slgnerii)request that the lnfotmallon provWed an ihb roan Ytlll bo_cofUldondoontWanllel,propdalary and:Indo eesnl.In aOeordanoe with TWa11/OOR,Seollo :r <br /> ,770 I;alas•,It aY•ueet Rmade for dbrm <br /> olosur•of lhle Info ndon,caIRacy cle vi III eonlaot the it narp)of lhla form at tho addreu end leUphdne number p_ovtldod on lhG fano or noafph <br /> a f���.r�R� rte„ � ��"�it <br /> �. . Hauiar-Address' ��(�'-�— SFX'--T �l`)••e.-- C-m, � :•. <br /> I' Business Name <br /> -Q � 6 < :,;�LrJ_ �LJ����❑� Address <br /> Cf 4 State and zip hyo t� �nTI� b <br /> , <br /> ❑ Common j7`ve .33 <br /> Carrier <br /> I Cedlfy.under penalty 11 par)ury under the laws of the Slate of CollfmNsi that the ItIlennetlon Provided above to trudand correeL In addlllon,l Am nWWAArjOhailats18calron of(his Inlormlflton may moult In suspension,rovooeljon,ordeNol of r newel of <br /> the Wai)aTbe H+Wt Regla(nllon plplulnt tq Pub)W Reeouroee.Codo ae00on 42960 odd may result lnolvll penalties up to S 28,000 par d+Y,p.�r,gtoteuon pf•d-NslaOva poh+Wes lap to$5,000 pervtolallon"suspensio,rovooay as dsormad In Public rawer <br /> oResource: <br /> Codawk� l _� • 6 <br /> Driver's Name(p t) Driver's Si nature !, nate <br /> Comprehensive Tre • F - e a • e <br /> irJ 6 0 5 4 5:5 3 .e1, C <br /> ...dcAt1s fit ia .: <br /> Ha IerTireRYa')ram iD• to t Ii.: r? ? r-r aGi i Te a e er• 'i <br /> � 9 �!'-•$i. Suffi#c � � � t , j.>v�� � �h!: ��Ph.n., ,�, <br /> t ;. '-+ err ., (.I };;:•:' ,a.i �"` �'> ,, t)�. It j:l ..i :r, B <br /> E <br /> : <br /> rig„�4`. f' 1 <br /> rar i T yz kS7 gY;yyt Wil{ of Facility Bilisiness <br /> .� � �'�:�/_ ��Q�;- 4 Na)nelltdLiross• <br /> `¢ Hauler NamoiEM <br /> l ': „'. � Fr i .'`_'� City,Mato Alict`Z..• t <br /> ' r 1 amp clr L <br /> t OK abe <br /> • <br /> Haulerrelepljone.Number 1 i 7 ❑ Address$amo as Hauler <br /> '�« rY ;h. •”�*•"` e 1," I CERTIFY THAT UNCER•PENALTY OF PERJURY OF THEj <br /> R ' M1+�j o LAWS OF THE STATE 4F OALIFORNIATRATTNe <br /> , <br /> { .. .' ,rr •..- zfb+_.. ,.t. INFORMATION PR OYIDEDABOVEISSRUEANO-QB [ <br /> ` Coinprehensive Trip Log Number Load Information Facility Tire • e <br /> gram ID Site Stiff ix <br /> �Y.y _ u ,� 1 e is._' r• ' <br /> 6054550 -- B � t 4� ► <br /> s' d Hauler The PrograthAW4 Slte=Sufflxtor►e Ku <br /> of, <br /> .. S i•-dim IFI` 011, <br /> ;aTLtII� 11 Iiess <br /> ''�) I; i.. ;• ' ,I ) ` s F _Ntnal���rq <br /> ,Hattlor Name' : '-� .t. ;:cd+ ` <br /> sf i I �� i S G e e R tc C- <br /> I <br /> Hauler Telephone Num s 1 ) ) ' {ni Addrosa.Same.-as.H alar <br /> Op bel' f..yrj _. f. e•, _ .. .A initials <br /> .' ( +r_ip'.riv•'i°u4 •s''i. 2xl?!a%yi':'?,=..' �,'.^ - <br /> '- m ( IOERTIFY THAT UNDER PENALTY OF PERJURY OF THE; <br /> �'� �" r g ., •4>; �;Af. -II' LAWS OFTHEOTATEOFCALIFORNIATHATTHE <br /> INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. <br /> ,`�i a + • • • pTad • '1 <br /> -- <br /> , <br /> st®`� 1 3. .is{7 -e` ,,, , e+ r t•fi 1 i. 4 �•r I r7 <br /> 71;:: v l _.'.`+e Yfer•:. F n .{A r �', c I .t .,, <br /> ! 1..:. x iY IT�•ft•;pYs, ; <br /> MA <br /> u _� jQir ��allj ./rff'LSe.� p tt i tete Imo^ �t% �: y PiC <igsrj<F.3}4r <br /> nest>,5i fi��i�"�ib�►i;� _ Aiti <br /> ) <br /> ji#{LS�}rJirryrrT f7�Fl#tJ� l t'� 1' s l r z� kJs i )` .. t{J 1.t <br /> 1 4 .F�Lr tlYd•'4T.P'R lrkJi ',+ N Uri <br /> e.Jylf <br /> qtr! 2 ti ) i t° i�',a '•}' ;..n�lyi.+ <br /> 4: r•T�te Ell, L <br /> r <br /> MOM" <br /> n'fi r •tea y` T� •• i. ` <br /> i' c.y 17c -4' r,.?�: : "'t�'`3" 1= 1 _ .u: >(r�^ -•= i l i 1� rlid' <br /> -?Ti <br /> rg' 5 l) DT?(PIl I �,�k <br /> ti l ars' r�+4 fr�� •l X�.'{.ill F'a� ,�v rF- "! y {GS AF x+ - ; <br /> N7R�,r 1 i <br /> }• Y � ,�,a; �_&� �3, �A �,U � A �4.x'40 R :v7?: c�3� .z3 � rr <br /> _. _. -..-...:n'y97 cam"= `.. '.....z..._:m4. .. xrkY..�,N",;.F,e. �r•t •:Y <br />