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i <br /> A Comprehe Dept,of Roaourcom Racyoflne and RacoVory ' <br /> sive Trip Log and Receipts 10002 P.0;Box1269,secr6lnento,CA90812-1260' <br /> CaiReICi X A M P 1. E 1 2 :3' -'" : • <br /> Comprehensive Trip Number <br /> 'SliieelQ <br /> ho) <br /> creAruavaTnl STRUCTIONS ON MACK OF PART 2 OT'TAP .S .P O D L <br /> r <br /> 17041.(ng ihle AOoastlamoiw TMp Log old of <br /> II-'r 171r(e)regpwtlhaltltelntormollon pravldedon Ul14 fotn7 W01 he conefde ad conlldanllagproprfofaty End tred0000ret,In a000Neno►wIIh 71110.1400R,Eadllon <br /> 77047 aUeq.,IfareyWdla made for dleclaure of lhl Informelion,OplRecycp will eontaot llw elgnet(a)df lM1le loan al Uro pddnu en lotephononumhsrprov(dod.on <br /> I;r.�:rJ's' �I�r't, `(,t.5t.)�:yi4a_kis_��„�fa)r t,r.tI14�•—d4x,?<-�,+II�4�r t � ti-tt-drhrxs�x•'-x��'��{>S'i`IQ:Et'�::��:'.'.=;t}'F•�S`t . r <br /> this <br /> istfZo�rm o`Jr.1nZ,oel/t. <br /> t Ilaulet,Address T//L'G" <br /> ') <br /> CEuslness Name <br /> Ai <br /> , 7 fi11VLr Address <br /> city,State and Zip U <br /> YI �• <br /> Y t1 IIIIII' r., � common L <br /> ...< ,. ......:4.. ._.!-1_,....,:,.,_ 1�.. ._s.:_..� °vas Carrit-)r <br /> I adVy Ware by of potfury under lheinwe of the Stel of CeIlloMo lhat lhs h forme0on pmvlded shove is Ito*end consol.In WNW,U aware that fa6lEo%don 61(hit Nfmmallon rtroy t In suapensfon,rovocellqn,or*fdot of ronswal.1 <br /> Iho Yl t6o Hhuier Registration purauanl la Puh116 Ree ureos Code aectlon 42000.ond may lasullin civil penalties up to 426,000 pet day,pe 4oleitott or odmMfetrallvo o"-IV <br /> ee up tot, or Mion par day as dok6rlhed In Pu66oRaourca <br /> Codi ieollon,12 8Y <br /> 7— - <br /> Dr ver's Name(print) Drt er' ignature Date <br /> Comprehensive <br /> s a Log ber ® e rograrn ID <br /> :��7L58003 <br /> -- � ff ix; <br /> up Dell e1 y� Site or.. ,. _ aaoaa � o a <br /> Hauler Fire Program ID / S te':SuffiX 'i.4T I! in, <br /> FSeIIIty Telephone Number't <br /> of <br /> ) <br /> t-acility OU-11-1es0 w <br /> Nc1me/ <br /> any Htauler N ne � `<ir� l a `c w P Clt'v'S,site 111, 41,;. <br /> + <br /> � +rt <br /> '� ,i ;s I ;:sittrnl� y•_.a'tl�r)•tel <br /> Hauler ela urnber Addl as Sarno as�HaulorInitials <br /> -- <br /> r K } <br /> N", <br /> x.1 9F itf� 1 CERTIFY THAT UNDER'PENALTY OP PERJUfjYQP THE <br /> +r` t i., ii t a e p`t ifi LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> 1 <br /> 71 <br /> — - r f•' • 'rr ''.�ra..,F_T x + _'pi INFORMATIO1 PROVIDED AE0VE r37RUE ArrO CORRECL <br /> t E?,`�Y� a a Log e' Load Information o <br /> e jmID. Site Suffix <br /> 5 58003 -r Flick Ulf pea l <br /> ” Hauler .ire Program ID 7 :SI a Suffix <br /> , <br /> mber <br /> DATE <br /> 111 <br /> Whole,Tdre Count ❑ Wolglrt I�i,L1)s, ,HP <br /> . <br /> 1sNa 7 v •eR•. V' Volunln Cubio Y(! wolghtj 7"fah N �a la clCt ;,t•( �l,tp ,tg I%' r <br /> :I I p. <br /> Halder am//s'' r I � I ;� � � <br /> I. . Stamp tit'1_abioi OK <br /> ■c fi Addres's Same as hlauler <br /> .f• Wpui 'r rjloph n Number mrlmre <br /> — �OW <br /> �� t 1 .21A�Y IAWSOYTOSTAY'OPENALTYOFPERJURY OFTHE tom, <br /> LAW80F7H�STATR'OFCgUFORNtATHATiNE •1� j <br /> - t 4•;iiZ. INFORMA710N PROVIDED AaoVE 19 TRUE Aµ0 CORRECT. 1 <br /> o ae InformationProgram <br /> p•. - 5 ,,, , ik3i,'ssISIiF�'�esY,,7.�Ft s� - _ F r I <br /> 58003 <br /> Haulie: <br /> 74 <br /> M r. ;;( t t1:1=�'.,1 3t y ,• u I <br /> e,PrQgram IIS / �e Sclif � � �� t � � ��; }y� i �1lbl�k�ai�e`:SN�l�'1.��► <br /> i r a " <br /> ,I•+,� ttrl}+rt2 15t r � (� t!t,�,�a 1f 1.�'I��) ��t'i }t� .d! ' f <br /> ' jrr,171 104 B I N—Ti�1 , <br /> N t " <br /> Hauler1;w t A <br /> •rl <br /> t 46H Iv, <br /> �iaulcr 1e1epit011C NUMber I-lauler <br /> HT1 f �R�R QF4.rtJURY0F THE 1189 ~ <br /> JAQt4NIAn AT'0iE <br /> ._-..� .:. ..._.+. <br /> ♦ZD O 'ANbAORfl LCL �, <br /> R A4OVa'IB`lRU� <br />