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 />
|