|
r
<br /> OopI.of Reeoyroea Racyollnp and Roco3ery
<br /> •� . CA Comprehensive Trip Log and Receipts i loom pa,13.1289,Sacramento,OA95M-1259
<br /> CaiRee1G(e t_ X A M P L E11.1'213 t Cont rehenslvejTrt Numbs
<br /> Jill
<br /> a,6O,c
<br /> EF
<br /> v .
<br /> c�m .p1glN$TRllCTIONS ON BACK OF PAR1"'2 DO NOT TAPE,STAPLE O DUPL'KATE :. .'"-�. ��g:-
<br /> ( DY,rtonNDUtle0A0ompreholtalvohlp Loa and Reablpt the atenar(a)roqueal thol tho Information provided on this form will be considered oonlldenllel,proprlalory and trodo aorot.In occorda000wllis Tlllo,14 CCR,Rebllon S
<br /> W041 ofseq.,Ile request to made for dfacloauro.0%a InformalIon,Celneo ole w0l oontaotlhe sfoner(1).01•Ihle form althe addro sand late,ane{n�umbvprovload on this form or receipt,
<br /> IiaulerAddress i C�t�
<br /> ,� a .:,>,FBusiness Name
<br /> g. �j{`.t.Ij^-?h,
<br /> ? Address City,State and zip rP-�b 4) 40 y>:4A V-.4 t�''1.
<br /> I
<br /> E, r It" Common Y q
<br /> . l"J t_..1
<br /> 1' l; '...t.. �3 Carrier �� , t�
<br /> I car0ly under penalty alp
<br /> the fawn of the State of California that His Information provided ahova U 1(ue and corral,In odpl(lon,I.am aware Thal fntsiffoellon of this Information mayraufl In suspenolon,Wfiordlon,of denial of tone•ml of
<br /> thew".TpeHmlorRe0l1,U fon.purA0anit0PublloResourcesCodesection42000andmayreeViInCIOP nd11aupto;26,000par tiny,pdrViolatidnoradmfnblrativopomlllo=upto;4,000pervlelatlonper day an described InPublic Re ourco,
<br /> Codaololl0 429pg, i
<br /> Vi 6,en'V_.r,0 . .r of .t _ c `- —l
<br /> Driver's Nome(PrInt)V Date
<br /> Comprehensive Trip Lc eNumber Loadn
<br /> Facility Tire Program ID
<br /> 575'7979 -'� CuMy�' ❑ ❑ n
<br /> ❑ ❑ ❑-❑ C
<br /> Mme,
<br /> t I A ta -(lity,'1"elephon� Number
<br /> Haulee Tire 0t0dratrr ID=/'Site SUffix
<br /> r
<br /> '�` ' �,•fir�i t;"x; L^� ��� jy,' ,❑'.❑ ❑ ❑
<br /> ailiLy Business
<br /> " I k , Na ne//�iitJiess.
<br /> Clt),State and'ZI►?
<br /> I ( c p Cir-hal
<br /> I � .
<br /> Hauler lela hone Nun er ❑ Address Same as Hauler n,,;,ns
<br /> p t�z•'�:.�i'-irl' `R '''"' e�� ��ty 'p� � I CERTIFYTHAT UNDER PBNALTYOFPERJURY OFTHE
<br /> .�`c 4 sY X f •• tVl 1 BS)
<br /> ) +. -i fi Y.t,., r SaMtr c'.NSn.''�lS r.. r,9raix�e7. INFORh1A INIATHAT THE
<br /> ON PROLAWS OFTHE M ED ADOOF IV FOje RUE AUD CORRECT.
<br /> Compeeh6risive,Trip INumber Load Information
<br /> 5757979 �- B � t pa . 1° ❑^ � ❑-❑,. l
<br /> V. [IT10.11,
<br /> » ' ' Fac(� Tete o, Pl4ttnber:
<br /> Hauler Tire Arogt`am':ID .L slte;Suff r�� � �� ', ,..� � :R� ��t
<br /> 1 �• •y4i
<br /> _ M.•'`��il' ��'
<br /> nh �M+uz! b SrwT T 4 7r �T R92` Y. i 'j inefl8
<br /> n irj © l '-• ��•r' �b}f► a >` 't�f ��� 1�h��,� �+ R��3c
<br /> 1 :•. . +.. .Y =, `M • rat Il �, ,� {
<br /> >a aulerName sy 1, ;,;:1;•' ;".:,} r; E�:,:.
<br /> T I }s l 1 1 i ❑ Address Samo as Hauler n lol�
<br /> Hauler Telephot o Nu rlbor : ,, t b . . _ ,..,
<br /> 'rh 4``-� Y^w'�,+�'! '£ .YVi! 3C•�•,2•Y�,i.:t�'dr.�'�'5', �';c (CERTIFY TFIATUNOER PENALTY OF PERJURY OF THE
<br /> s •`E Y^� {I'aTtt ` b w LAWS OF THE STATE OF CALIFORNIA,THATTNE
<br /> G C/ �' 359`i »v�•'< 'a,-t•;i q,r " INFORMATION PROVIDED AEOVEISTRUEANO COR ECT. •�
<br /> Comprehensive a Log Number Load InformationProgram I1) Site suffix
<br /> 5757979
<br /> t1Qui�Tire hrogralij IA / tie Suff1X �� I' a �i r t, t I 'ti J� l a' Utt1b 1
<br /> �1 I Ila ❑ ❑:❑
<br /> 1.flllr j„� I �nJ ;i) �J Yrs���t(Y'�a7�,,(tp� .� ✓ l/ ✓ I �'
<br /> IC 1 .'
<br /> tR;�;,t)>!:'1' 1'.J i,Sf,' 1,t •�j'� ,t N i'qo n .S
<br /> j. 'f r,•r, W �'
<br /> ti�
<br /> q�8 hne; um? r 4 t✓ r1R� y}t�t l utlFig1l r l ays
<br /> 4 y•; � •�,Yu�i r•! -��(• .•L 't�i+"'a'� elf s �'1��� � D .d �t4HA
<br /> e
<br /> �I( dE ` t f7 1yisl E T �tH
<br /> -
<br /> R V •t
<br />
|