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• RApt.of Reeouroes Reoyoling and Recovery
<br /> 02- CA Comprehensive Trip Log and Receipts 10002 R0:6ox1260,5aoromento,CA05012-1250
<br /> Cfl1ft00 CI9. . X A M P L 1 2 3
<br /> Com rehenslve,Trt Number
<br /> stelear0"p"' INSTRUCTIONS ON BACK OF PART 2 DO NOT TAP 5TAPLE OR DUPLI AT>r ®2
<br /> CilAW N.}p7Fl0}. �r -
<br /> ay.lyYntnp thle 9A Oomprehenalae Trip Lae and Receipt,the d11naie)request that Ilia Information provided`on tuts form will bs'nonNdefed oonlldontfd,proprietaryend trade secret.In acoorduncgwllh Tllls;14 COR,Section
<br /> 1T041Yt0cit"if ersquut Is made for dnolosuro of this Infonnalionf Cal Reoyalo will con trial the d11nes(s)of this farm at the Riialtses and telephone number provided.onlhlrlmm or reaoip6
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<br /> Hauler Addir i✓u , I
<br /> 1Slla 3bti �l�l�hibel rik1, ;,, r coo lye I I
<br /> t3usiness Name
<br /> ....; (� Address 1-�2�C� ` n �� '•,
<br /> a a City,State and Zip -
<br /> ICehso-Plate Number state, � �� ,• � r�r�3
<br /> aL71 Q n o C ier
<br /> IoorUfy under pdnally of penury under ib 01, of Ute 81016 of CalllornlatMlthe lnlorrMlbn provided allow Ulrue end correct,In nddlllon,lem aware that fatelRcnllon L+Inlaa"an rosin suspension,rovooallon,or pedal elreoawal of
<br /> lite WnN!TN!Hauler Re IT ballon pursuant to PW2o A.urece Code%action d211e0.and moy fault N cMI penalties up to S 26,000 ps per vtdetion or admirals; Yap elllo%u 85, 0 vialallon per day As dotomlbed In Pubyo Hatourew
<br /> CodffaP6 421182
<br /> ,!/G`G.t%Y�1 c.�a!�GliC�l•U'��d•�2•i/J '� �;'-1 C�i
<br /> Driver's Name(print) DrIvelilif Signature Date
<br /> Compre-hensive Trip Log Number Load Information' 'Facility Tire.Program ID Site Suffix
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<br /> 5757702
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<br /> y ' Hauler Tire Program In / Site Su x• 'f' " rt,>r; ! a� Facility Telephone e w , rDf Count ul,ht s �o o a a a o a a
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<br /> 4 olunle Gub •Yds, elgilt it Tins Nat •?/A klrerl;
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<br /> R, y Hauler Name } ray,{�iLltc)and 7
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<br /> Stwnp of-Latini OK
<br /> .hiaUler TZI:lhone Number
<br /> ;'�� �, Adclress Same as Hauler Initials
<br /> 1101111"
<br /> � � I CERTIFY THAT UNDER PENALTY OFPIIRJURY OF Tile
<br /> LAtY90FTNE STATE 0P 0ALiFORNIA TFIAT THE
<br /> rr., ,4uilf�i' r'Ra :);'4i�w i. r'I INFORMATION PROVIDED ABOVE 187RUEANO CORRECT 7-
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<br /> 757702 �" B {aIC{C U� tjbEilVCt'y
<br /> Hauler.TireProgeam-10 / Site'Sufflx: a fy T �'' � ' / Facility Tele0hone.Number.
<br /> w �jt Whole fi-Ire CountWeight In hbe �
<br /> e3lz,❑Wolght I11 Tafts'j N.71I1ca/ I
<br /> ` Hauler Name (•Ity, 444
<br /> '()+' i ✓ iE l ;'ilt'ur11J I-A,
<br /> HEiuler Telephone Number. d �� Address Same as Hauler D Is
<br /> (NIA fora`. _J I CBkTIFYTHAT UNDER PENALTYOF PERJURYOFTHE '
<br /> `sG��•• G��j�'� 'r'�rr7 lhllolo Tires),_ LAWS OF-THE 87ATE OF OALIFORNIA THATTH6
<br /> 4/WWW :::3 INFORMATION PROVIDED ADOYti 1S TRUE All D OORRECT.
<br /> iComprehensive Trip Log'Number Load Information Facility Tire Program ID Site suffix;�
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<br /> {{�ee tw-� fir•'-�77 t,;;n/,.; ;r. r ggS�, z.,S� ° q yr .� r u�)(� F 1•'CT�j 4� i� f
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<br /> Hau.1prTire Program;lD % Site Suffix 77!11121
<br /> ' �,�,)>� If? Faelitt�Telephone Number '
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<br /> ;i tl Ill �.
<br /> ,.. . : /, � � •'� ;alb'-�tj��igt,�, I(
<br /> aulet N�m6`
<br /> iitL7
<br /> H ,•SiBf €I� Y a �;;'4tiQr P _
<br /> - Jr.iler`fulr. hrTtle t�lumb�r � ,
<br /> § Initials
<br /> t { Up9ATIFt(��I f Orh6CNARY-b'90NJt�ttY PFTHE
<br /> �✓. -,. t>�{ -- - �-�. r '(. LAV18'Ofl TN8f7'�.�Of C7t41PO6tilATHAi'1HE
<br /> �` g _ LNFORWITI.(1 !t pEp ASOYEJ9,TRIIH ANO.00RRE07
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