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' Dep6 0. issouro•a 60yollnu and lleotivety ` <br /> CA Comprehensive Trip Lag and Receipts 10002 o:Box 1269,Saoralnenlo,CA96812.1269 <br /> Com -rehenslve Tri N mbe <br /> C�1Rec c(e x ',�' M P L. <br /> r= r 'z a ' �mi� <br /> Wald.bfdek! e� <br /> rral;INST RUCTIONS ON BACK OF IRAt'�T:2: .DO;NOT TAPB STAPt F OR D.UPI.I.CAT6 ' e ,=.` °z a7Sy.Ionlnathl.CAOemproheneivoTHpLoosndn000pl,theetanet(s)roqu.dlhatlholnlormattamprov{dadonIN*faimWillhp.aonoiderodoonfldinllaLproprietary.and IrodeeeareL In nauordencewlleaBas el i <br /> 170.1 of seq.,Il n requaal to mddo fordlsoiauro otlhle lnlonnallen,oaIReoyl8 vdh boblaoUhe slenar(s)of this format the address dad telephone number provided on lila form or r000lp6 <br /> Mauler Address <br /> r,�� Business Name <br /> • , <br /> t ` �,i • Address <br /> pQ`r , 4� pi3pp �``buy City,StStB and ZIP #u M 7'i <br /> "' <br /> common : Z � <br /> l cBllEy undarpenetty of pequry under Noiewe of lhg6lnla of C•Iilornld that the Information provld.d above is truoand coneol:In addition,l am aware that falelOoaUon of this lnformallon may result In suspension:revocation,or doolid offsn Wolof I <br /> IhgWa•ihToaHwkr(topklrel!onpurananitoPub;bRroourceaDodoeecl!on42060and mayrosultInoYi7penN0asuptoS26,000per day,parvioldllonor.edniNetmllvepenol0esuptoSS,00DporNolAIWpardayasdeeodbed!oPubOoR psouidst ! <br /> Cod••ep6on 42002 <br /> Driver's it ( r►it) privet's Slynaturs Aate <br /> Facility'Tire Program ID, <br /> 0�5 4 5 5.2 am No c � � 3 ol�i���ry 0 0 � OE LLD <br /> Hauler Tire.�Program-lb*•I- Sife'SuffIx. <br /> f <br /> I 1! Fa�llity;Tetepi�onelNurr1}iel:•! I <br /> In <br /> (fit yh '^•'�"L"'3t9�. ��jh <br /> 1� uoAMj � Q-0 <br /> al:t� ��µ�::V. CaciliL ESusines a <br /> ,{ � I �,r�'�0�,�� � � �� ��� ��•''Nanit� •''•Idrlafs , + .. <br /> Hauler Nanl ,;'s.;},�:li? rr �.?zrt 'y� .��:a" CII�/r a�afH`6 c{l1dl' Ir. <br /> .. 1 of I .,I + : 1 ;t I l I�. ! ': .. �: � ..: <br /> V s S I Iffy ( St6ITtp or 1_a gel CK <br /> k ;, 411. <br /> Hauler Telephone Number T i i , �� El Address Salne as Hauler -- <br /> R#'i! OERTIRY'fNATUt7DERPEItALTYOFPERJURYOFTHE <br /> LAWS OF THE STATE OF CALIFORNIATRATTHE <br /> NFORMATIONPROIADEOAaDVSISTRUEANDCMECT. <br /> Comprehenisive Trip Log Number Load Information Facility Tir e Program ID <br /> RF <br /> 60545 <br /> 52 <br /> onN <br /> :Ha ler Tire Pra$raiaU,;/ �Site:801- b <br /> er; <br /> 4T IT <br /> Y <br /> i <br /> t ' <br /> NO, <br /> -r <br /> %flE,Miolf The+ <br /> � ( moss <br /> �* ili�jVglyt>ie�C I el ttlV��� fhNo' I�r:tress: <br /> - C!:i .t'':t `"Cn.*e .� .;to �a 4rf� ,.ui? s't y'Cif+'It SII,d l e1✓�,1 y`•'�, <br /> p Hauler Name <br /> IN <br /> . f Address Same as Hauler <br /> Hauler Telephone Number :- . . ra. <br /> l(�afyC f w r isl- �q ICERTIPI(THAT UNDER PENALTY OF PERJURY OFT E <br /> LAWS OF THE STATE OF CALIFORNIA THAT THE . <br /> INFORMATION PROVIDED ABOVE 1E,TRUEAND 6DA OL <br /> Ot- I <br /> e Ia - • • I KoIr.I• e T-11([#I in • a 11 <br /> q i <br /> `—'l^a[ ! 7ljl lzrlh'1`; t xiti(S +i !.r•-.. _ rdr . <br /> 6a 5 �- S iI <br /> 4I.. t�J '' 6 r:AtllS ! ( t 4atntyi ' , <br /> T>� � <br /> Halllor Tiro prodKatTt 117 f ll� 1'Su{'{yf�1 <br /> ka <br /> IL.f�:i1I13'­ <br /> AW., <br /> 7� :rAyl6 <br /> a r <br /> : <br /> 3 <br /> Y i <br /> Of 06 it I e <br /> 6. <br /> 4 cSt r <br /> > r Y y <br /> t <br /> ��, y�.�y{�wrr��(� <br /> """LIF+ _ 1rATjrr}�'L{ y •f:l <br /> -�....,-.. i.....c.. r•+�.-....... ,...J ,..,-�v:w..-•ry-..,:. .-.._.... ..... - .:v_.:tee_ (_ <br /> ��i �'y��orZ��IJIpfi f3 ` <br /> . ... .. -., .. �, RO oioA 3�c P��U <br />